Provider Demographics
NPI:1750519930
Name:TEODORU, MALINA
Entity type:Individual
Prefix:
First Name:MALINA
Middle Name:
Last Name:TEODORU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14376 ASPEN AVE NE
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-1307
Mailing Address - Country:US
Mailing Address - Phone:952-992-0282
Mailing Address - Fax:
Practice Address - Street 1:13550 26TH AVE N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-3650
Practice Address - Country:US
Practice Address - Phone:763-557-0287
Practice Address - Fax:763-557-0295
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12674122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND12674OtherMN BOARD OF DENTISTRY