Healthcare Provider Details

I. General information

NPI: 1417062969
Provider Name (Legal Business Name): DAVID MICHAEL DITCH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 E MILL ST
PELICAN RAPIDS MN
56572
US

IV. Provider business mailing address

PO BOX 342
PELICAN RAPIDS MN
56572
US

V. Phone/Fax

Practice location:
  • Phone: 218-863-5858
  • Fax: 218-863-1143
Mailing address:
  • Phone: 218-863-5858
  • Fax: 218-863-1143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD10376
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: