Organization Name: | FOND DU LAC RESERVATION BUSINESS COMMITTE |
NPI Number: | 1063723138 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | KAREN R DIVER (CHAIRWOMAN) |
Mailing Address: | 927 Trettel Lane Fond Du Lac Human Services Division Dental Clinic Cloquet |
State: | MN US |
Postal Code: | 55720 |
Phone Number: | 2188791227 |
Fax Number: | 2188783755 |
NPI Enumeration Date: | 06/23/2010 |
NPI Last Update Date: | 06/23/2010 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QD0000X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MN |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Dental |
Taxonomy Definition: |