Provider Demographics
NPI:1467146555
Name:MORENO, TEVIN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:TEVIN
Middle Name:MICHAEL
Last Name:MORENO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:TEVIN
Other - Middle Name:MICHAEL
Other - Last Name:DOUGLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1114 LABREE AVE N
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-1222
Mailing Address - Country:US
Mailing Address - Phone:218-686-9361
Mailing Address - Fax:
Practice Address - Street 1:318 LABREE AVE N
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-2037
Practice Address - Country:US
Practice Address - Phone:218-653-1165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2023-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND148951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice