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General NPI Number Information
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NPI Number | 1952709420
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Entity Type | Organization
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Legal Business Name | ST. CROIX ENDODONTICS
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Dates
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Enumeration Date | 12/15/2014
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Last Update Date | 11/23/2020
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Provider Practice Location Address
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Address Line | 25 LAKE ST N SUITE 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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Provider Business Mailing Address
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Address Line | 25 LAKE ST N SUITE 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 | OFFICE MANAGER
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Name | SERENA JEAN PEDERSEN
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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 |
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License Number State |
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