Healthcare Provider Details

I. General information

NPI: 1073461810
Provider Name (Legal Business Name): TWIN CITIES CHILDREN'S GENERAL ANESTHESIA DENTISTRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1997 SLOAN PL STE 30
MAPLEWOOD MN
55117-2051
US

IV. Provider business mailing address

1997 SLOAN PL STE 30
MAPLEWOOD MN
55117-2051
US

V. Phone/Fax

Practice location:
  • Phone: 651-383-3333
  • Fax: 651-383-8888
Mailing address:
  • Phone: 651-383-3333
  • Fax: 651-661-7375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number StateNULL

VIII. Authorized Official

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