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General NPI Number Information
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NPI Number | 1053591255
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Entity Type | Organization
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Legal Business Name | ADVANCE FAMILY DENTAL
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Dates
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Enumeration Date | 11/06/2007
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Last Update Date | 11/06/2007
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Provider Practice Location Address
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Address Line | 925 COUNTY ROAD E E SUITE 185
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City | VADNAIS HEIGHTS
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State | MN
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Zip | 55127-7179
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Country | US
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Telephone | 651-482-1122
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Fax | 651-766-2557
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Provider Business Mailing Address
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Address Line | 925 COUNTY ROAD E E SUITE 185
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City | VADNAIS HEIGHTS
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State | MN
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Zip | 55127-7179
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Country | US
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Telephone | 651-482-1122
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Fax | 651-766-2557
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MOLLY SEIDL
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Credential |
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Telephone | 651-482-1122
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 12387
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 9142
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License Number State | MN
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