Provider Demographics
NPI:1710098819
Name:KOLLODGE, THOMAS L (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:L
Last Name:KOLLODGE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1309
Mailing Address - Street 2:MAIL CODE 21113A
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-1309
Mailing Address - Country:US
Mailing Address - Phone:952-883-5151
Mailing Address - Fax:952-883-5160
Practice Address - Street 1:5100 GAMBLE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416
Practice Address - Country:US
Practice Address - Phone:952-593-0779
Practice Address - Fax:952-595-6451
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN95491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice