1770540502 NPI number — TWIN CITIES ENDODONTIC SPECIALISTS, P.A.

Table of content: (NPI 1770540502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770540502 NPI number — TWIN CITIES ENDODONTIC SPECIALISTS, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TWIN CITIES ENDODONTIC SPECIALISTS, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770540502
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2550 UNIVERSITY AVE W
Provider Second Line Business Mailing Address:
SUITE 155S
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55114-1052
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-646-6386
Provider Business Mailing Address Fax Number:
651-649-3074

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2550 UNIVERSITY AVE W
Provider Second Line Business Practice Location Address:
SUITE 155S
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55114-1052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-646-6386
Provider Business Practice Location Address Fax Number:
651-649-3074
Provider Enumeration Date:
04/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WELTERS
Authorized Official First Name:
DEB
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
651-646-6386

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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