Healthcare Provider Details

I. General information

NPI: 1174706865
Provider Name (Legal Business Name): TWIN CITIES PERIODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 EXCELSIOR BLVD STE 180
ST LOUIS PARK MN
55426-4713
US

IV. Provider business mailing address

6600 EXCELSIOR BLVD STE 180
ST LOUIS PARK MN
55426-4713
US

V. Phone/Fax

Practice location:
  • Phone: 952-935-9009
  • Fax: 952-935-1006
Mailing address:
  • Phone: 952-935-9009
  • Fax: 952-935-1006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD11998
License Number StateMN

VIII. Authorized Official

Name: DR. ANTHONY J SKINNER
Title or Position: OWNER
Credential: DDS
Phone: 952-935-9009