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General NPI Number Information
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NPI Number | 1386166734
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Entity Type | Organization
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Legal Business Name | SOUTHRIDGE DENTAL, PA
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Dates
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Enumeration Date | 07/07/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1320 MENDOTA RD
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City | INVER GROVE HEIGHTS
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State | MN
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Zip | 55077-1255
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Country | US
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Telephone | 651-451-1884
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Fax | 651-306-9709
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Provider Business Mailing Address
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Address Line | 1320 MENDOTA RD
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City | INVER GROVE HEIGHTS
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State | MN
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Zip | 55077-1255
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Country | US
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Telephone | 651-451-1884
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | SHERYL BOTTJEN TANDON
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Credential | DDS
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Telephone | 651-451-1884
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D12847
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License Number State | MN
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