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General NPI Number Information
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NPI Number | 1013153352
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Entity Type | Organization
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Legal Business Name | ASSOCIATED DENTISTS SHOLOM HOME
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Dates
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Enumeration Date | 12/16/2008
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Last Update Date | 12/16/2008
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Provider Practice Location Address
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Address Line | 1371 7TH ST W SUITE B
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City | SAINT PAUL
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State | MN
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Zip | 55102-4205
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Country | US
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Telephone | 651-488-5557
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Fax | 651-488-0014
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Provider Business Mailing Address
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Address Line | 1371 7TH ST W SUITE B
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City | SAINT PAUL
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State | MN
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Zip | 55102-4205
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Country | US
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Telephone | 651-488-5557
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Fax | 651-488-0014
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Authorized Official
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Title or Position | SITE MANAGER
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Name | ANGIE LOFT
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Credential |
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Telephone | 651-488-5557
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 11152
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D11202
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License Number State | MN
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