Healthcare Provider Details

I. General information

NPI: 1083400733
Provider Name (Legal Business Name): MR. ISAAC LARSEN TADE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2025
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 PLYMOUTH AVE N
MINNEAPOLIS MN
55411-3600
US

IV. Provider business mailing address

2707 GARFIELD AVE APT 3
MINNEAPOLIS MN
55408-1345
US

V. Phone/Fax

Practice location:
  • Phone: 612-543-2500
  • Fax:
Mailing address:
  • Phone: 507-589-9171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1083400733
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: