=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003429515
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OMEGA DENTAL CARE, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2020
-----------------------------------------------------
Last Update Date | 08/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6203 DELL RD
-----------------------------------------------------
City | EDEN PRAIRIE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55346-1122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-460-9100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1161 WAYZATA BLVD E # 210
-----------------------------------------------------
City | WAYZATA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55391-1935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ANNELLE SOBERAY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 952-460-9100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------