Provider Demographics
NPI:1023107224
Name:DIEM, THOMAS J (DDS, MD)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:J
Last Name:DIEM
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12010 53RD AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442-1834
Mailing Address - Country:US
Mailing Address - Phone:763-557-1353
Mailing Address - Fax:
Practice Address - Street 1:500 OSBORNE RD NE
Practice Address - Street 2:UNITY PROFESSIONAL BLDG SUITE 350
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2765
Practice Address - Country:US
Practice Address - Phone:763-780-8927
Practice Address - Fax:763-780-1286
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24664174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1305105OtherMEDICA ID
MN03507AEOtherBCBS ID
MNA95678Medicare UPIN