Healthcare Provider Details

I. General information

NPI: 1184023772
Provider Name (Legal Business Name): PREETANJALI THAKUR BDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2014
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 UNIVERSITY AVENUE WEST SUITE 189S
ST PAUL MN
55114
US

IV. Provider business mailing address

2550 UNIVERSITY AVENUE WEST SUITE 189S
ST PAUL MN
55114
US

V. Phone/Fax

Practice location:
  • Phone: 651-332-7474
  • Fax: 651-332-7475
Mailing address:
  • Phone: 651-332-7474
  • Fax: 651-332-7475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License NumberS127
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberR607
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: