Healthcare Provider Details

I. General information

NPI: 1487847752
Provider Name (Legal Business Name): ENDODONTIC PROFESSIONALS PA ST CLOUD ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 NORTHWAY DRIVE SUITE 210
ST CLOUD MN
56303
US

IV. Provider business mailing address

1555 NORTHWAY DRIVE SUITE 210
ST CLOUD MN
56303
US

V. Phone/Fax

Practice location:
  • Phone: 320-259-5078
  • Fax: 320-259-1484
Mailing address:
  • Phone: 320-259-5078
  • Fax: 320-259-1484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number8575456
License Number StateMN

VIII. Authorized Official

Name: THOMAS A KARN
Title or Position: VICE PRESIDENT
Credential: DMD
Phone: 320-259-5078