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General NPI Number Information
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NPI Number | 1063723138
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Entity Type | Organization
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Legal Business Name | FOND DU LAC RESERVATION BUSINESS COMMITTE
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Dates
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Enumeration Date | 06/23/2010
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Last Update Date | 06/23/2010
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Provider Practice Location Address
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Address Line | 927 TRETTEL LANE FOND DU LAC HUMAN SERVICES DIVISION DENTAL CLINIC
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City | CLOQUET
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State | MN
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Zip | 55720
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Country | US
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Telephone | 218-879-1227
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Fax | 218-878-3755
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Provider Business Mailing Address
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Address Line | 927 TRETTEL LANE FOND DU LAC HUMAN SERVICES DIVISION DENTAL CLINIC
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City | CLOQUET
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State | MN
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Zip | 55720
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Country | US
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Telephone | 218-879-1227
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Fax | 218-878-3755
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Authorized Official
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Title or Position | CHAIRWOMAN
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Name | KAREN R DIVER
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Credential |
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Telephone | 218-879-4593
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State | MN
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