Provider Demographics
NPI:1518027754
Name:MINNESOTA STATE COMMUNITY AND TECHNICAL COLLEGE - DENTAL
Entity Type:Organization
Organization Name:MINNESOTA STATE COMMUNITY AND TECHNICAL COLLEGE - DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR DENTAL DEPARTMEN
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MBA
Authorized Official - Phone:218-299-6819
Mailing Address - Street 1:1900 28TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-4830
Mailing Address - Country:US
Mailing Address - Phone:218-299-6560
Mailing Address - Fax:218-299-6532
Practice Address - Street 1:1900 28TH AVE S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-4830
Practice Address - Country:US
Practice Address - Phone:218-299-6560
Practice Address - Fax:218-299-6532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND041211Medicaid
ND041211Medicaid