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General NPI Number Information
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NPI Number | 1629199617
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Entity Type | Organization
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Legal Business Name | ST. CROIX ENDODONTICS, P.A.
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Dates
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Enumeration Date | 04/03/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 11945 CENTRAL AVE NE
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City | BLAINE
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State | MN
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Zip | 55434-3911
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Country | US
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Telephone | 763-767-9119
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Fax | 763-755-3797
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Provider Business Mailing Address
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Address Line | 25 LAKE ST N STE 110
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City | FOREST LAKE
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State | MN
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Zip | 55025-2535
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Country | US
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Telephone | 651-464-7388
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Fax | 651-982-6236
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Authorized Official
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Title or Position | OWNER
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Name | DR. EDWARD J STEC
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Credential |
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Telephone | 763-767-9119
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 9920
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License Number State | MN
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