Basic Information
| Provider Information | |||||||||
| NPI: | 1063723138 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOND DU LAC RESERVATION BUSINESS COMMITTE | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FOND DU LAC HUMAN SERVICES DIVISION DENTAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 927 TRETTEL LANE | ||||||||
| Address2: | FOND DU LAC HUMAN SERVICES DIVISION DENTAL CLINIC | ||||||||
| City: | CLOQUET | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188791227 | ||||||||
| FaxNumber: | 2188783755 | ||||||||
| Practice Location | |||||||||
| Address1: | 927 TRETTEL LANE | ||||||||
| Address2: | FOND DU LAC HUMAN SERVICES DIVISION DENTAL CLINIC | ||||||||
| City: | CLOQUET | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188791227 | ||||||||
| FaxNumber: | 2188783755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2010 | ||||||||
| LastUpdateDate: | 06/23/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DIVER | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRWOMAN | ||||||||
| AuthorizedOfficialTelephone: | 2188794593 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FOND DU LAC RESERVATION BUSINESS COMMITTEE | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | MN | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | 666815100 | 05 | MN | MEDICAID |