Provider Demographics
NPI:1699964320
Name:VANSURKSUM, RODERICK DUANE (DDS)
Entity type:Individual
Prefix:
First Name:RODERICK
Middle Name:DUANE
Last Name:VANSURKSUM
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 1:11601 MINNETONKA MILLS RD STE F40
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-5189
Mailing Address - Country:US
Mailing Address - Phone:952-935-8420
Mailing Address - Fax:952-935-0147
Practice Address - Street 1:11601 MINNETONKA MILLS RD STE F40
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5189
Practice Address - Country:US
Practice Address - Phone:952-935-8420
Practice Address - Fax:952-935-0147
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND114171223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN704432100Medicaid