Provider Demographics
NPI:1073994653
Name:THIELE, MARK BENJAMIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:BENJAMIN
Last Name:THIELE
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:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:WARROAD
Mailing Address - State:MN
Mailing Address - Zip Code:56763-0490
Mailing Address - Country:US
Mailing Address - Phone:218-386-1048
Mailing Address - Fax:218-386-1049
Practice Address - Street 1:301 STATE AVE SW
Practice Address - Street 2:
Practice Address - City:WARROAD
Practice Address - State:MN
Practice Address - Zip Code:56763-2623
Practice Address - Country:US
Practice Address - Phone:218-386-1048
Practice Address - Fax:218-386-1049
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13533122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist