Provider Demographics
NPI:1720367394
Name:HEIDENREICH, THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:HEIDENREICH
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:CENTRASOTA ORAL SURGEONS
Mailing Address - Street 2:3950 VETERANS DRIVE, SUITE 100
Mailing Address - City:ST. CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-252-3611
Mailing Address - Fax:320-252-7574
Practice Address - Street 1:3950 VETERANS DR STE 100
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-3424
Practice Address - Country:US
Practice Address - Phone:320-252-3611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-12
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNS1691223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery