Provider Demographics
NPI:1972722908
Name:SEDIVY, MARY L (DDS)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:L
Last Name:SEDIVY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1480 YANKEE DOODLE RD
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-1801
Mailing Address - Country:US
Mailing Address - Phone:651-452-3333
Mailing Address - Fax:
Practice Address - Street 1:1480 YANKEE DOODLE RD
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-1801
Practice Address - Country:US
Practice Address - Phone:651-452-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111801223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics