=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033170857
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAIN STREET FAMILY DENTAL CARE P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 411 MAIN ST SUITE 308
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55102-1080
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-227-6561
-----------------------------------------------------
Fax | 651-297-6852
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 411 MAIN ST SUITE 308
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55102-1080
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-227-6561
-----------------------------------------------------
Fax | 651-297-6852
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MISS JAYNE F. GROUT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-227-6561
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 9068
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------