Healthcare Provider Details

I. General information

NPI: 1861877599
Provider Name (Legal Business Name): TEAL TWADDLE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2015
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5816 OSAGE BEACH PKWY STE 107
OSAGE BEACH MO
65065-3065
US

IV. Provider business mailing address

5816 OSAGE BEACH PKWY STE 107
OSAGE BEACH MO
65065-3065
US

V. Phone/Fax

Practice location:
  • Phone: 573-693-9017
  • Fax:
Mailing address:
  • Phone: 660-853-1005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2015020717
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2015020717
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: