Healthcare Provider Details

I. General information

NPI: 1053427237
Provider Name (Legal Business Name): SANDSTONE DENTAL OFFICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N COMMERCIAL AVE
SANDSTONE MN
55072-0589
US

IV. Provider business mailing address

501 N COMMERCIAL AVE PO BOX 589
SANDSTONE MN
55072-0589
US

V. Phone/Fax

Practice location:
  • Phone: 320-245-2208
  • Fax: 320-245-2208
Mailing address:
  • Phone: 320-245-2208
  • Fax: 320-245-2208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8046
License Number StateMN

VIII. Authorized Official

Name: DR. MICHAEL MAURICE BENNETT
Title or Position: OWNER DENTIST
Credential: DDS
Phone: 320-245-2208