Healthcare Provider Details

I. General information

NPI: 1174812689
Provider Name (Legal Business Name): ZACHARY J BAILEY DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 6TH ST NE
STAPLES MN
56479
US

IV. Provider business mailing address

515 6TH ST NE
STAPLES MN
56479
US

V. Phone/Fax

Practice location:
  • Phone: 218-894-1941
  • Fax: 218-894-5729
Mailing address:
  • Phone: 218-894-1941
  • Fax: 218-894-5729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD11468
License Number StateMN

VIII. Authorized Official

Name: ZACHARY J BAILEY
Title or Position: OFFICER
Credential: DDS
Phone: 218-894-1941