Provider Demographics
NPI:1780790881
Name:TONKA SMILES
Entity type:Organization
Organization Name:TONKA SMILES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BERGSTEADT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-938-8533
Mailing Address - Street 1:11601 MINNETONKA MILLS RD
Mailing Address - Street 2:STE D40
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305
Mailing Address - Country:US
Mailing Address - Phone:952-938-8533
Mailing Address - Fax:952-938-9321
Practice Address - Street 1:11601 MINNETONKA MILLS RD
Practice Address - Street 2:STE D40
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305
Practice Address - Country:US
Practice Address - Phone:952-938-8533
Practice Address - Fax:952-938-9321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10769122300000X
MN11571122300000X
MN8734122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN056216500Medicaid
MN168135400Medicaid
MN773218000Medicaid