Active NPI
Miranda Thacker, DDS
- Pediatric Dentistry
- Minneapolis, MN
National Provider Identifier
1710876578
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Dentistry
- License
- D15303
- Practice address
- 701 25TH Ave S Ste 400
Minneapolis, MN 55454-1443 - Phone
- (612) 626-7232
- NPI assigned
- Jun 28, 2025
- Last updated
- Jun 28, 2025
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Dentistry | 1223P0221X | D15303 | MN | Primary |
Addresses
Primary practice location
701 25TH Ave S Ste 400
Minneapolis, MN 55454-1443
Mailing address
8994 Neill Lake Rd
Eden Prairie, MN 55347-2036
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MN
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20250728003540 | MN | Order and Referring Only - Pediatric Dentistry | 3971010687 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| D15303 | MN | MD | Pediatric Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1751068800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1751068800000",
"number": "1710876578",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "8994 NEILL LAKE RD",
"city": "EDEN PRAIRIE",
"state": "MN",
"postal_code": "553472036"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "701 25TH AVE S STE 400",
"city": "MINNEAPOLIS",
"state": "MN",
"postal_code": "554541443",
"telephone_number": "612-626-7232"
}
],
"practiceLocations": [],
"basic": {
"last_name": "THACKER",
"first_name": "MIRANDA",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2025-06-28",
"last_updated": "2025-06-28",
"certification_date": "2025-06-28",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "MN",
"license": "D15303",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Minneapolis, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 28, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.