Basic Information
| Provider Information | |||||||||
| NPI: | 1164996997 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. CROIX DENTAL HEALTH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 235 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | SAINT CROIX FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540244117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154833261 | ||||||||
| FaxNumber: | 7154830507 | ||||||||
| Practice Location | |||||||||
| Address1: | 26425 LAKELAND AVE S | ||||||||
| Address2: | |||||||||
| City: | WEBSTER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548938343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158664420 | ||||||||
| FaxNumber: | 7158664368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2019 | ||||||||
| LastUpdateDate: | 11/12/2019 | ||||||||
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| AuthorizedOfficialLastName: | MORTEL | ||||||||
| AuthorizedOfficialFirstName: | TANYA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7154830429 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.