Provider Demographics
NPI:1265493159
Name:TERVOLA, STEPHEN JOSEPH (DDS)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JOSEPH
Last Name:TERVOLA
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 1:1172 AQUARIUS LN
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-1824
Mailing Address - Country:US
Mailing Address - Phone:651-683-9497
Mailing Address - Fax:
Practice Address - Street 1:3624 E LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-2152
Practice Address - Country:US
Practice Address - Phone:612-729-2361
Practice Address - Fax:612-729-2362
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND86861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice