Basic Information
| Provider Information | |||||||||
| NPI: | 1437198694 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DASHIELL | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 KENNARD ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551095465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512327800 | ||||||||
| FaxNumber: | 6512327940 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 KENNARD ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551095465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512327800 | ||||||||
| FaxNumber: | 6512327940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2006 | ||||||||
| LastUpdateDate: | 06/26/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 22135 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 298888700 | 05 | MN | MEDICAID |