=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972760098
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VALLEY CREEK FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2008
-----------------------------------------------------
Last Update Date | 05/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6949 VALLEY CREEK RD SUITE 100
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-731-1054
-----------------------------------------------------
Fax | 651-731-2183
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6949 VALLEY CREEK RD SUITE 100
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-731-1054
-----------------------------------------------------
Fax | 651-731-2183
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST PRESIDENT
-----------------------------------------------------
Name | JILL MARIE ASH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 651-731-1054
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 10284
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------