Provider Demographics
NPI:1073258471
Name:TLA DDS PLLC
Entity Type:Organization
Organization Name:TLA DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIARA
Authorized Official - Middle Name:
Authorized Official - Last Name:APPLEQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-281-1301
Mailing Address - Street 1:2211 SAHLSTROM DR STE A
Mailing Address - Street 2:
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716-2827
Mailing Address - Country:US
Mailing Address - Phone:218-281-1301
Mailing Address - Fax:
Practice Address - Street 1:2211 SAHLSTROM DR STE A
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716-2827
Practice Address - Country:US
Practice Address - Phone:218-281-1301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-29
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental