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General NPI Number Information
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NPI Number | 1386335602
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Entity Type | Organization
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Legal Business Name | 3RD STREET DENTAL LLC
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Dates
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Enumeration Date | 05/17/2023
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Last Update Date | 05/17/2023
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Provider Practice Location Address
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Address Line | 212 3RD ST STE 5
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City | TRACY
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State | MN
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Zip | 56175-1267
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Country | US
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Telephone | 507-626-8826
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Fax |
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Provider Business Mailing Address
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Address Line | 3RD STREET DENTAL LLC PO BOX 1153
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City | TRACY
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State | MN
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Zip | 56175
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Country | US
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Telephone | 646-710-0666
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | MELISSA ISRAEL
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Credential | DDS
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Telephone | 646-710-0666
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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 |
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License Number State |
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