MEDICARE: DR. TEAL TWADDLE 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	2015020717	MO
2	122300000X	Dentist	2015020717	MO

General Provider Information

NPI Number	:	1861877599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TEAL TWADDLE DDS

Provider Business Mailing Address
First Line	:	5816 OSAGE BEACH PKWY STE 107
Second Line	:
City	:	OSAGE BEACH
State	:	MO
Zip	:	65065-3065
Country	:	US
Telephone Number	:	660-853-1005
Fax Number	:

Provider Business Practice Location Address
First Line	:	5816 OSAGE BEACH PKWY STE 107
Second Line	:
City	:	OSAGE BEACH
State	:	MO
Zip	:	65065-3065
Country	:	US
Telephone Number	:	573-693-9017
Fax Number	:

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

Provider Enumeration Date	:	07/23/2015
Last Update Date	:	08/04/2020

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