Healthcare Provider Details

I. General information

NPI: 1205863693
Provider Name (Legal Business Name): SANDRA K DOLPHIN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 S ADAMS ST
ST CROIX FALLS WI
54024
US

IV. Provider business mailing address

213 SOUTH ADAMS STREET
ST CROIX FALLS WI
54024
US

V. Phone/Fax

Practice location:
  • Phone: 715-483-3259
  • Fax: 715-483-5136
Mailing address:
  • Phone: 715-483-3259
  • Fax: 715-483-5136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2589-035
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: