Healthcare Provider Details

I. General information

NPI: 1851364392
Provider Name (Legal Business Name): JULIE A CHAVEZ DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 10/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 GAMBLE DR SUITE 125
ST LOUIS PARK MN
55416-1521
US

IV. Provider business mailing address

5100 GAMBLE DR SUITE 125
ST LOUIS PARK MN
55416-1521
US

V. Phone/Fax

Practice location:
  • Phone: 952-465-0105
  • Fax: 952-465-0106
Mailing address:
  • Phone: 952-465-0105
  • Fax: 952-465-0106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD11399
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: