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General NPI Number Information
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NPI Number | 1922450634
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Entity Type | Organization
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Legal Business Name | BOREALIS DENTAL STUDIO, P.A.
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Dates
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Enumeration Date | 07/06/2016
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Last Update Date | 07/06/2016
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Provider Practice Location Address
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Address Line | 12745 N 1ST AVE
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City | LINDSTROM
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State | MN
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Zip | 55045-9585
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Country | US
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Telephone | 651-257-2720
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Fax |
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Provider Business Mailing Address
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Address Line | 6892 256TH ST
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City | WYOMING
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State | MN
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Zip | 55092-8362
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Country | US
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Telephone | 405-837-3159
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Fax |
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | BECKY GOOLSBY
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Credential |
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Telephone | 405-837-3159
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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 | D13152
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License Number State | MN
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