Provider Demographics
NPI:1841030939
Name:THAO, BAO SHIRLEY (DMD)
Entity type:Individual
Prefix:
First Name:BAO
Middle Name:SHIRLEY
Last Name:THAO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6445 LYNDALE AVE S APT 513
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-7569
Mailing Address - Country:US
Mailing Address - Phone:916-281-6067
Mailing Address - Fax:
Practice Address - Street 1:701 25TH AVE S STE 400
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1443
Practice Address - Country:US
Practice Address - Phone:916-281-6067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-28
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND15052122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist