=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730602905
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAREPOINT DENTAL CRYSTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2017
-----------------------------------------------------
Last Update Date | 12/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 331 WILLOW BND
-----------------------------------------------------
City | CRYSTAL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55428-3969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-354-7683
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 331 WILLOW BND
-----------------------------------------------------
City | CRYSTAL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55428-3969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MOHAMMAD SALAD
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 763-354-7683
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D12779
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------