Healthcare Provider Details

I. General information

NPI: 1376222547
Provider Name (Legal Business Name): TWIN CITIES CHILDREN'S GENERAL ANESTHESIA DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2023
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1997 SLOAN PL
MAPLEWOOD MN
55117-2047
US

IV. Provider business mailing address

1220 CARAWAY CT STE 1050
UPPER MARLBORO MD
20774-5338
US

V. Phone/Fax

Practice location:
  • Phone: 301-494-3000
  • Fax:
Mailing address:
  • Phone: 301-494-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: JEFFERY WHEELER
Title or Position: CEO
Credential:
Phone: 301-494-3000