Healthcare Provider Details

I. General information

NPI: 1063723138
Provider Name (Legal Business Name): FOND DU LAC RESERVATION BUSINESS COMMITTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 06/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 TRETTEL LANE FOND DU LAC HUMAN SERVICES DIVISION DENTAL CLINIC
CLOQUET MN
55720
US

IV. Provider business mailing address

927 TRETTEL LANE FOND DU LAC HUMAN SERVICES DIVISION DENTAL CLINIC
CLOQUET MN
55720
US

V. Phone/Fax

Practice location:
  • Phone: 218-879-1227
  • Fax: 218-878-3755
Mailing address:
  • Phone: 218-879-1227
  • Fax: 218-878-3755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateMN

VIII. Authorized Official

Name: KAREN R DIVER
Title or Position: CHAIRWOMAN
Credential:
Phone: 218-879-4593