South River Dental PLLC

Primary specialty

Dental Clinic/CenterTaxonomy code 261QD0000X

Legal business name

SOUTH RIVER DENTAL PLLC

Practice address

1545 Livingston Ave Ste 101
West St Paul, MN 55118-3422

Phone

(651) 455-0505

NPI assigned

May 2, 2022

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Clint Matthew Kroeker, DDSNPI 1518451707

Title

President

Phone

(651) 455-0505

Specialties & licenses 1

Addresses

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Clint Matthew Kroeker, DDS

  • General Practice Dentistry
  • West St Paul, MN
  • NPI 1518451707
  NPD Authorized official
• William Sterling Johnston, DDS

  • Dentist
  • West Saint Paul, MN
  • NPI 1881769131
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1651449600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1651449600000",
    "number": "1154066405",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1545 LIVINGSTON AVE STE 101",
            "city": "WEST ST PAUL",
            "state": "MN",
            "postal_code": "551183422",
            "telephone_number": "651-455-0505"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1545 LIVINGSTON AVE STE 101",
            "city": "WEST ST PAUL",
            "state": "MN",
            "postal_code": "551183422",
            "telephone_number": "651-455-0505"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH RIVER DENTAL PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-05-02",
        "last_updated": "2022-05-02",
        "certification_date": "2022-05-02",
        "status": "A",
        "authorized_official_last_name": "KROEKER",
        "authorized_official_first_name": "CLINT",
        "authorized_official_middle_name": "MATTHEW",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "651-455-0505",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• All providers in West St Paul, MN
• Dental Clinic/Center in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 2, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.