Provider Demographics
NPI:1972683183
Name:MINNESOTA STATE UNIVERSITY
Entity Type:Organization
Organization Name:MINNESOTA STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRPERSON
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNNETTE
Authorized Official - Middle Name:M
Authorized Official - Last Name:ENGESWICK
Authorized Official - Suffix:
Authorized Official - Credentials:RDH, MS
Authorized Official - Phone:507-389-5848
Mailing Address - Street 1:3 MORRIS HALL
Mailing Address - Street 2:DENTAL CLINIC
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6043
Mailing Address - Country:US
Mailing Address - Phone:507-389-1313
Mailing Address - Fax:507-389-5850
Practice Address - Street 1:3 MORRIS HALL
Practice Address - Street 2:DENTAL CLINIC
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6043
Practice Address - Country:US
Practice Address - Phone:507-389-1313
Practice Address - Fax:507-389-5850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8361251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN=========OtherTAX I.D.