Provider Demographics
NPI:1447956875
Name:STATE OF MINNESOTA MINNESOTA MANAGEMENT AND BUDGET
Entity type:Organization
Organization Name:STATE OF MINNESOTA MINNESOTA MANAGEMENT AND BUDGET
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MDVA CHIEF OPERATIONS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SIMONE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:HOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-505-4110
Mailing Address - Street 1:5101 MINNEHAHA AVE. S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1647
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1821 N. PARK STREET
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-1247
Practice Address - Country:US
Practice Address - Phone:218-736-0400
Practice Address - Fax:612-548-5964
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF MINNESOTA MINNESOTA MANAGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-02-07
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty