Healthcare Provider Details

I. General information

NPI: 1336765254
Provider Name (Legal Business Name): CAITLIN SPACEK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2704 12TH ST S
MOORHEAD MN
56560-4621
US

IV. Provider business mailing address

1650 45TH ST S STE 108
FARGO ND
58103-3247
US

V. Phone/Fax

Practice location:
  • Phone: 218-233-0570
  • Fax:
Mailing address:
  • Phone: 701-526-4652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD14526
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2404
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: