Provider Demographics
NPI:1265481881
Name:DIMICH, THOMAS PETER (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:PETER
Last Name:DIMICH
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 1:104 FOSSE CT
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-2605
Mailing Address - Country:US
Mailing Address - Phone:218-681-1088
Mailing Address - Fax:
Practice Address - Street 1:310 RED LAKE BLVD
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-2133
Practice Address - Country:US
Practice Address - Phone:218-681-2545
Practice Address - Fax:218-681-2560
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN75341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN63233 DIOtherBLUE CROSS BLUE SHIELD