Provider Demographics
NPI:1104996867
Name:MILLE LACS BAND OF OJIBWE INDIANS
Entity type:Organization
Organization Name:MILLE LACS BAND OF OJIBWE INDIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COMMISSIONER OF HEALTH & HUMAN SERV
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-532-4163
Mailing Address - Street 1:18562 MINOBIMAADIZI LOOP
Mailing Address - Street 2:
Mailing Address - City:ONAMIA
Mailing Address - State:MN
Mailing Address - Zip Code:56359-3001
Mailing Address - Country:US
Mailing Address - Phone:320-532-4163
Mailing Address - Fax:
Practice Address - Street 1:18562 MINOBIMAADIZI LOOP
Practice Address - Street 2:
Practice Address - City:ONAMIA
Practice Address - State:MN
Practice Address - Zip Code:56359-2241
Practice Address - Country:US
Practice Address - Phone:320-532-4163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILLE LACS BAND OF OJIBWE INDIANS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-09
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD0000X
MND11497122300000X
MNH6243124Q00000X
MNH5056124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Not Answered122300000XDental ProvidersDentistGroup - Single Specialty
Not Answered124Q00000XDental ProvidersDental HygienistGroup - Single Specialty