Provider Demographics
NPI:1740587468
Name:THOMAS P. DIMICH, DDS, PA
Entity Type:Organization
Organization Name:THOMAS P. DIMICH, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:DIMICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-681-2545
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:56701-2133
Mailing Address - Country:US
Mailing Address - Phone:218-681-2545
Mailing Address - Fax:218-681-2560
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN75341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN376513000OtherMN HEALTHCARE PROGRAM