Provider Demographics
NPI:1598837932
Name:BERGSTEDT, TIMOTHY MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MARK
Last Name:BERGSTEDT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5008 WOODHURST LN
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-4644
Mailing Address - Country:US
Mailing Address - Phone:952-934-1769
Mailing Address - Fax:
Practice Address - Street 1:11601 MINNETONKA MILLS RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5161
Practice Address - Country:US
Practice Address - Phone:952-938-8533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8734122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01312BEOtherBLUE CROSS PROVIDER NO,
MN8734OtherSTATE DENTAL LICENSE