Healthcare Provider Details

I. General information

NPI: 1952430753
Provider Name (Legal Business Name): SPRING VALLEY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 N BROADWAY ST
SPRING VALLEY MN
55975-1029
US

IV. Provider business mailing address

PO BOX 232
SPRING VALLEY MN
55975-0232
US

V. Phone/Fax

Practice location:
  • Phone: 507-346-7281
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: GENIE KUBLE
Title or Position: CONTACT OFFICER
Credential:
Phone: 920-450-0157