MEDICARE: SOUTHRIDGE DENTAL, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	D12847	MN

General Provider Information

NPI Number	:	1386166734
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHRIDGE DENTAL, PA

Provider Business Mailing Address
First Line	:	1320 MENDOTA RD
Second Line	:
City	:	INVER GROVE HEIGHTS
State	:	MN
Zip	:	55077-1255
Country	:	US
Telephone Number	:	651-451-1884
Fax Number	:

Provider Business Practice Location Address
First Line	:	1320 MENDOTA RD
Second Line	:
City	:	INVER GROVE HEIGHTS
State	:	MN
Zip	:	55077-1255
Country	:	US
Telephone Number	:	651-451-1884
Fax Number	:	651-306-9709

Authorized Official
Title or Position	:	DENTIST
Name	:	SHERYL BOTTJEN TANDON
Credential	:	DDS
Telephone Number	:	651-451-1884

Provider Enumeration Date	:	07/07/2017
Last Update Date	:	07/21/2022

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