=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003021239
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STAT DENTAL, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2233 HAMLINE AVE N SUITE 432
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55113-5009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-778-9911
-----------------------------------------------------
Fax | 651-633-0146
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15043 BRIDGEWATER DR
-----------------------------------------------------
City | SAVAGE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55378-5618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-859-7359
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. TIMOTHY J GIBLETTE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-859-7359
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------