Provider Demographics
NPI:1063834588
Name:CHASKA PEDIATRIC DENTISTRY, P.A.
Entity Type:Organization
Organization Name:CHASKA PEDIATRIC DENTISTRY, P.A.
Other - Org Name:TAILWIND PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-475-3135
Mailing Address - Street 1:250 CENTRAL AVE N
Mailing Address - Street 2:SUITE 113
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-1206
Mailing Address - Country:US
Mailing Address - Phone:952-475-3135
Mailing Address - Fax:
Practice Address - Street 1:111 HUNDERTMARK RD
Practice Address - Street 2:SUITE 304N
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-4551
Practice Address - Country:US
Practice Address - Phone:952-475-3135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12818261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental