Provider Demographics
NPI:1407039274
Name:PAUL M TRYGSTAD
Entity Type:Organization
Organization Name:PAUL M TRYGSTAD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:M
Authorized Official - Last Name:TRYGSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-834-2354
Mailing Address - Street 1:123 WATERFRONT DR
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-1525
Mailing Address - Country:US
Mailing Address - Phone:218-834-2354
Mailing Address - Fax:
Practice Address - Street 1:123 WATERFRONT DR
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-1525
Practice Address - Country:US
Practice Address - Phone:218-834-2354
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9087122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN389822900Medicaid