Provider Demographics
NPI:1639463706
Name:EICKMAN, MICHAEL DALE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DALE
Last Name:EICKMAN
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 655
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-0655
Mailing Address - Country:US
Mailing Address - Phone:218-681-2545
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:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12920122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice