Provider Demographics
NPI:1124198254
Name:IMDIEKE, AARON DANIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:AARON
Middle Name:DANIEL
Last Name:IMDIEKE
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 280
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-0280
Mailing Address - Country:US
Mailing Address - Phone:320-252-6233
Mailing Address - Fax:320-525-9261
Practice Address - Street 1:1201 MAINE PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4881
Practice Address - Country:US
Practice Address - Phone:320-252-6233
Practice Address - Fax:320-252-9261
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice