Individual
DR. TARA VONNE BRODERSEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
DDS
Contact information
Practice address
200 UNIVERSITY AVE E, SAINT PAUL, MN 55101-2507
(651) 291-2848
(651) 602-6885
Mailing address
200 UNIVERSITY AVE E, SAINT PAUL, MN 55101-2507
(651) 291-2848
(651) 602-6885
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
D11913
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
H400538336
MEDICARE UPIN
MN
Enumeration date
10/18/2005
Last updated
03/08/2019
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