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General NPI Number Information
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NPI Number | 1144717299
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Entity Type | Organization
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Legal Business Name | GREAT ODENS, LLC
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Dates
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Enumeration Date | 04/14/2018
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Last Update Date | 11/19/2020
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Provider Practice Location Address
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Address Line | 241 CLEVELAND AVE S STE D
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City | SAINT PAUL
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State | MN
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Zip | 55105-1208
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Country | US
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Telephone | 651-699-3212
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Fax | 651-698-8898
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Provider Business Mailing Address
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Address Line | 241 CLEVELAND AVE S STE D
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City | SAINT PAUL
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State | MN
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Zip | 55105-1208
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Country | US
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Telephone | 651-699-3212
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Fax | 651-698-8898
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Authorized Official
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Title or Position | OWNER
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Name | DR. CARLEY ODENS
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Credential | DDS
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Telephone | 701-370-3200
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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 | D13542
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License Number State | MN
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