Provider Demographics
NPI:1710114921
Name:JAGGER, THYRA
Entity Type:Individual
Prefix:
First Name:THYRA
Middle Name:
Last Name:JAGGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1670 BEAM AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-1201
Mailing Address - Country:US
Mailing Address - Phone:651-925-8400
Mailing Address - Fax:651-925-8439
Practice Address - Street 1:1670 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1201
Practice Address - Country:US
Practice Address - Phone:651-925-8400
Practice Address - Fax:651-925-8439
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12672122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist