Healthcare Provider Details

I. General information

NPI: 1700104072
Provider Name (Legal Business Name): STEIDL FAMILY DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 07/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 37TH AVE S
MOORHEAD MN
56560
US

IV. Provider business mailing address

915 37TH AVE S
MOORHEAD MN
56560-6148
US

V. Phone/Fax

Practice location:
  • Phone: 218-236-9319
  • Fax:
Mailing address:
  • Phone: 218-236-9319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD12067
License Number StateMN

VIII. Authorized Official

Name: DR. JAMIE W STEIDL
Title or Position: OWNER
Credential: DDS
Phone: 218-236-9319