MEDICARE: DAKOTA PEDIATRIC DENTISTRY PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	2000	ND

General Provider Information

NPI Number	:	1578898268
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAKOTA PEDIATRIC DENTISTRY PC

Provider Business Mailing Address
First Line	:	2812 17TH AVE S
Second Line	:	SUITE F
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-4048
Country	:	US
Telephone Number	:	701-746-1400
Fax Number	:

Provider Business Practice Location Address
First Line	:	2812 17TH AVE S
Second Line	:	SUITE F
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-4048
Country	:	US
Telephone Number	:	701-746-1400
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	DR. CHAD JAMES HOGE
Credential	:	DDS
Telephone Number	:	701-200-5771

Provider Enumeration Date	:	10/13/2009
Last Update Date	:	10/13/2009

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