1992107122 NPI number — DAKOTA DENTAL

Table of content: (NPI 1992107122)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992107122 NPI number — DAKOTA DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAKOTA DENTAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PHEASANT RUN DENTAL CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992107122
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2605 19TH AVE W
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
WILLISTON
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58801-2892
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-577-3333
Provider Business Mailing Address Fax Number:
701-577-3336

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2605 19TH AVE W
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
WILLISTON
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58801-2892
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-577-3333
Provider Business Practice Location Address Fax Number:
701-577-3336
Provider Enumeration Date:
09/18/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BLACKHURST
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
701-577-3333

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  2210 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QD0000X , with the licence number: 2209 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QD0000X , with the licence number: 2208 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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