Healthcare Provider Details

I. General information

NPI: 1053184762
Provider Name (Legal Business Name): MJW ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2023
Last Update Date: 11/03/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

531 S 7TH ST
BISMARCK ND
58504-5859
US

IV. Provider business mailing address

531 S 7TH ST
BISMARCK ND
58504-5859
US

V. Phone/Fax

Practice location:
  • Phone: 701-224-1558
  • Fax:
Mailing address:
  • Phone: 701-224-1558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN MICHAEL WELK
Title or Position: ORTHODONTIST
Credential: DDS, MS
Phone: 701-220-3578