Provider Demographics
NPI:1336138882
Name:BRODERSEN, TARA VONNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:VONNE
Last Name:BRODERSEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 UNIVERSITY AVE E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-2507
Mailing Address - Country:US
Mailing Address - Phone:651-291-2848
Mailing Address - Fax:651-602-6885
Practice Address - Street 1:200 UNIVERSITY AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2507
Practice Address - Country:US
Practice Address - Phone:651-291-2848
Practice Address - Fax:651-602-6885
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND119131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400538336OtherMEDICARE UPIN