Provider Demographics
NPI:1568546992
Name:REGENTS OF THE UNIVERSITY OF MINNESOTA
Entity Type:Organization
Organization Name:REGENTS OF THE UNIVERSITY OF MINNESOTA
Other - Org Name:HIBBING COMMUNITY COLLEGE DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEAN
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-626-6529
Mailing Address - Street 1:1515 E 25TH ST
Mailing Address - Street 2:ROOM C-153
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-3354
Mailing Address - Country:US
Mailing Address - Phone:218-263-2917
Mailing Address - Fax:218-263-2971
Practice Address - Street 1:1515 E 25TH ST
Practice Address - Street 2:ROOM C-153
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-3354
Practice Address - Country:US
Practice Address - Phone:218-263-2917
Practice Address - Fax:218-263-2971
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGENTS OF THE UNIVERSITY OF MINNESOTA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-24
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN936450100Medicaid