MEDICARE: THOMAS PETER DIMICH DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	7534	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	63233 DI	OTHER	MN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1265481881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS PETER DIMICH DDS

Provider Business Mailing Address
First Line	:	104 FOSSE CT
Second Line	:
City	:	THIEF RIVER FALLS
State	:	MN
Zip	:	56701-2605
Country	:	US
Telephone Number	:	218-681-1088
Fax Number	:

Provider Business Practice Location Address
First Line	:	310 RED LAKE BLVD
Second Line	:
City	:	THIEF RIVER FALLS
State	:	MN
Zip	:	56701-2133
Country	:	US
Telephone Number	:	218-681-2545
Fax Number	:	218-681-2560

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/09/2006
Last Update Date	:	07/08/2007

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