MEDICARE: DR. STEPHEN JOSEPH TERVOLA DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D8686	MN

General Provider Information

NPI Number	:	1265493159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN JOSEPH TERVOLA DDS

Provider Business Mailing Address
First Line	:	1172 AQUARIUS LN
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55123-1824
Country	:	US
Telephone Number	:	651-683-9497
Fax Number	:

Provider Business Practice Location Address
First Line	:	3624 E LAKE ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-2152
Country	:	US
Telephone Number	:	612-729-2361
Fax Number	:	612-729-2362

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2006
Last Update Date	:	07/08/2007

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