Organization
NORTH ST. PAUL DENTAL
Active
Parent organization
MAHTOMEDI DENTAL CLINIC
Organization subpart
Yes
Provider details
NPI number
Legal business name
MAHTOMEDI DENTAL CLINIC
Authorized official
DR. TIMOTHY A BRAY DDS (OWNER/ DENTIST)
(651) 770-6260
Entity
Organization
Contact information
Practice address
2082 11TH AVE E, NORTH ST PAUL, MN 55109-5112
(651) 770-6260
Mailing address
814 MAHTOMEDI AVE, MAHTOMEDI, MN 55115-1730
(651) 426-0011
(651) 426-2075
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
8217
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
982017500
—
MN
Enumeration date
12/17/2008
Last updated
12/17/2008
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