Provider Demographics
NPI:1801080353
Name:AESTHETIC-RECONSTRUCTIVE PLASTIC SURGERY, LTD
Entity type:Organization
Organization Name:AESTHETIC-RECONSTRUCTIVE PLASTIC SURGERY, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:DIEM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:763-780-8927
Mailing Address - Street 1:500 OSBORNE RD NE
Mailing Address - Street 2:UNITY PROFESSIONAL BLDG SUITE 350
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2765
Mailing Address - Country:US
Mailing Address - Phone:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24664174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC00776OtherMEDICARE GROUP ID
MN03507AEOtherBCBS ID
MNC00776OtherMEDICARE GROUP ID