Healthcare Provider Details

I. General information

NPI: 1518027754
Provider Name (Legal Business Name): MINNESOTA STATE COMMUNITY AND TECHNICAL COLLEGE - DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 28TH AVE S
MOORHEAD MN
56560-4830
US

IV. Provider business mailing address

1900 28TH AVE S
MOORHEAD MN
56560-4830
US

V. Phone/Fax

Practice location:
  • Phone: 218-299-6560
  • Fax: 218-299-6532
Mailing address:
  • Phone: 218-299-6560
  • Fax: 218-299-6532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS L BOE
Title or Position: DIRECTOR DENTAL DEPARTMEN
Credential: DDS, MBA
Phone: 218-299-6819