MEDICARE: STILLWATER MODERN DENTISTRY. PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1629774138
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STILLWATER MODERN DENTISTRY. PC

Provider Business Mailing Address
First Line	:	PO BOX 920050
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75392-0050
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13331 60TH ST N
Second Line	:
City	:	OAK PARK HEIGHTS
State	:	MN
Zip	:	55082-1287
Country	:	US
Telephone Number	:	651-352-4629
Fax Number	:	651-359-2935

Authorized Official
Title or Position	:	OWNER
Name	:	KRISTA JEAN KOEHLER
Credential	:
Telephone Number	:	651-352-4629

Provider Enumeration Date	:	02/06/2023
Last Update Date	:	02/06/2023

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