Healthcare Provider Details

I. General information

NPI: 1457276297
Provider Name (Legal Business Name): SKYTLAND PERIO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1142 W CAPITOL AVE
BISMARCK ND
58501-1306
US

IV. Provider business mailing address

1142 W CAPITOL AVE
BISMARCK ND
58501-1306
US

V. Phone/Fax

Practice location:
  • Phone: 701-222-8760
  • Fax:
Mailing address:
  • Phone: 701-222-8760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: BRADY SKYTLAND
Title or Position: MANAGING MEMBER
Credential: DMD
Phone: 701-222-8760