Healthcare Provider Details

I. General information

NPI: 1639222904
Provider Name (Legal Business Name): THOMAS L BJORGE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 PLYMOUTH ST NE
LE MARS IA
51031
US

IV. Provider business mailing address

35 PLYMOUTH STREET NE
LE MARS IA
51031
US

V. Phone/Fax

Practice location:
  • Phone: 712-546-5183
  • Fax:
Mailing address:
  • Phone: 712-546-5183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5552
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: