Healthcare Provider Details

I. General information

NPI: 1073994653
Provider Name (Legal Business Name): MARK BENJAMIN THIELE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2015
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 STATE AVE SW
WARROAD MN
56763-2623
US

IV. Provider business mailing address

PO BOX 490
WARROAD MN
56763-0490
US

V. Phone/Fax

Practice location:
  • Phone: 218-386-1048
  • Fax: 218-386-1049
Mailing address:
  • Phone: 218-386-1048
  • Fax: 218-386-1049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD13533
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: