Provider Demographics
NPI:1861877599
Name:TWADDLE, TEAL (DDS)
Entity type:Individual
Prefix:DR
First Name:TEAL
Middle Name:
Last Name:TWADDLE
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 1:5816 OSAGE BEACH PKWY STE 107
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3065
Mailing Address - Country:US
Mailing Address - Phone:660-853-1005
Mailing Address - Fax:
Practice Address - Street 1:5816 OSAGE BEACH PKWY STE 107
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3065
Practice Address - Country:US
Practice Address - Phone:573-693-9017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-23
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20150207171223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice