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General NPI Number Information
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NPI Number | 1518171081
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Entity Type | Organization
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Legal Business Name | DR. STEPHANIE GRUENES CENTER FOR COSMETIC DENTISTRY PA
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Dates
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Enumeration Date | 05/10/2007
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Last Update Date | 03/11/2010
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Provider Practice Location Address
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Address Line | 13734 FIRST STREET
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City | BECKER
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State | MN
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Zip | 55308
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Country | US
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Telephone | 763-262-7645
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Fax | 763-262-2345
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Provider Business Mailing Address
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Address Line | P.O. BOX 38 13734 FIRST STREET
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City | BECKER
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State | MN
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Zip | 55308
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Country | US
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Telephone | 763-262-7645
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Fax | 763-262-2345
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Authorized Official
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Title or Position | CHEIF EXECUTIVE OFFICER
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Name | DR. STEPHANIE L GRUENES
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Credential | D.D.S.
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Telephone | 763-262-7645
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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 | D11331
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License Number State | MN
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