=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568481760
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAMES C. E. ANDREA AND LYNNETTE K. E. ANDREA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1230 COUNTY ROAD E E
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55110-5132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-482-0180
-----------------------------------------------------
Fax | 651-482-7957
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1230 COUNTY ROAD E E
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55110-5132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-482-0180
-----------------------------------------------------
Fax | 651-482-7957
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL PARTNER
-----------------------------------------------------
Name | DR. JAMES C. E. ANDREA
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 651-482-0180
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 10099
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 11489
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 9959
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------