MEDICARE: DR. MICHAEL DALE EICKMAN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	D12920	MN
2	1223G0001X	General Practice Dentistry	D12920	MN

General Provider Information

NPI Number	:	1639463706
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL DALE EICKMAN DDS

Provider Business Mailing Address
First Line	:	PO BOX 655
Second Line	:
City	:	THIEF RIVER FALLS
State	:	MN
Zip	:	56701-0655
Country	:	US
Telephone Number	:	218-681-2545
Fax Number	:

Provider Business Practice Location Address
First Line	:	310 RED LAKE BLVD
Second Line	:
City	:	THIEF RIVER FALLS
State	:	MN
Zip	:	56701-2133
Country	:	US
Telephone Number	:	218-681-2545
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2011
Last Update Date	:	06/06/2011

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