Provider Demographics
NPI:1851408165
Name:THIERER, TODD ERIC (DDS)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:ERIC
Last Name:THIERER
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 1:8170 33RD AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-883-5151
Mailing Address - Fax:529-883-5160
Practice Address - Street 1:2500 COMO AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108
Practice Address - Country:US
Practice Address - Phone:651-647-2525
Practice Address - Fax:651-632-8984
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041625-11223G0001X
MND13000122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01354916Medicaid
7876OtherBLUE SHIELD GROUP NUMBER
7876OtherBLUE SHIELD GROUP NUMBER