Provider Demographics
NPI:1871750026
Name:TWIN CITIES DENTAL
Entity type:Organization
Organization Name:TWIN CITIES DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:VASSEUR
Authorized Official - Suffix:
Authorized Official - Credentials:RDA
Authorized Official - Phone:612-782-7000
Mailing Address - Street 1:3803 SILVER LAKE RD NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55421-4574
Mailing Address - Country:US
Mailing Address - Phone:612-782-7000
Mailing Address - Fax:612-782-7005
Practice Address - Street 1:3803 SILVER LAKE RD NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55421-4574
Practice Address - Country:US
Practice Address - Phone:612-782-7000
Practice Address - Fax:612-782-7005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND121421223G0001X
MND120341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN937605400Medicaid
MN243672800Medicaid