Healthcare Provider Details

I. General information

NPI: 1700449907
Provider Name (Legal Business Name): THOMAS MORIEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 24TH AVE S STE 200
MINNEAPOLIS MN
55454-1437
US

IV. Provider business mailing address

1016 WASHINGTON AVE SE APT 402
MINNEAPOLIS MN
55414-4091
US

V. Phone/Fax

Practice location:
  • Phone: 612-659-8689
  • Fax: 612-659-8690
Mailing address:
  • Phone: 612-672-2450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD14164
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: