=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215591573
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIANA M BARSNESS DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2019
-----------------------------------------------------
Last Update Date | 05/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1915 COUNTY ROAD D E
-----------------------------------------------------
City | MAPLEWOOD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55109-5309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-779-9002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 424 1ST AVE SE
-----------------------------------------------------
City | GLENWOOD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56334-1718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-808-6276
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | D14165
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------