Healthcare Provider Details

I. General information

NPI: 1184667305
Provider Name (Legal Business Name): FACE AND JAW SURGEONS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 04/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 W CAPITOL AVE
BISMARCK ND
58501-9956
US

IV. Provider business mailing address

1730 BURNT BOAT DR STE 300
BISMARCK ND
58503-0886
US

V. Phone/Fax

Practice location:
  • Phone: 701-258-7220
  • Fax: 701-222-2329
Mailing address:
  • Phone: 701-258-7220
  • Fax: 701-222-2329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH R DEATHERAGE
Title or Position: DMD MD
Credential: DMD MD
Phone: 701-258-7220