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General NPI Number Information
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NPI Number | 1508318247
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Entity Type | Organization
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Legal Business Name | TRACY M. ST. DENNIS, D.D.S., PLLC
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Dates
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Enumeration Date | 10/28/2016
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Last Update Date | 10/28/2016
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Provider Practice Location Address
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Address Line | 3475 WILLOW LAKE BLVD SUITE 100
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City | VADNAIS HEIGHTS
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State | MN
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Zip | 55110-5156
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Country | US
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Telephone | 651-341-2106
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Fax |
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Provider Business Mailing Address
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Address Line | 3475 WILLOW LAKE BLVD SUITE 100
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City | VADNAIS HEIGHTS
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State | MN
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Zip | 55110-5156
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Country | US
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Telephone | 651-341-2106
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Fax |
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Authorized Official
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Title or Position | GENERAL MANAGER
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Name | MARK ST DENNIS
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Credential |
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Telephone | 651-341-2106
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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 |
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License Number State |
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