1811036247 NPI number — MRS. TYESHA DAWN MARIE DENT PA-C

Table of content: MRS. TYESHA DAWN MARIE DENT PA-C (NPI 1811036247)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811036247 NPI number — MRS. TYESHA DAWN MARIE DENT PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DENT
Provider First Name:
TYESHA
Provider Middle Name:
DAWN MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SITSLER
Provider Other First Name:
TYESHA
Provider Other Middle Name:
DAWN MARIE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1811036247
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6857 HWY. 21
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELGIN
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-584-3246
Provider Business Mailing Address Fax Number:
701-584-3011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 NORTH MAIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELGIN
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-584-3010
Provider Business Practice Location Address Fax Number:
701-584-3011
Provider Enumeration Date:
02/05/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PAC0361 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 11228 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 28537 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".