Provider Demographics
NPI:1306905724
Name:STADSKLEV, SCOTT PATRICK (DDS)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:PATRICK
Last Name:STADSKLEV
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 22ND AVE E
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308
Mailing Address - Country:US
Mailing Address - Phone:320-762-0100
Mailing Address - Fax:888-763-0267
Practice Address - Street 1:220 22ND AVE E
Practice Address - Street 2:SUITE 105
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308
Practice Address - Country:US
Practice Address - Phone:320-762-0100
Practice Address - Fax:888-763-0267
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND122711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN613642700Medicaid