Healthcare Provider Details

I. General information

NPI: 1104035252
Provider Name (Legal Business Name): TERRY LYNN DWELLE MD, MPHTM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 N 5TH ST
BISMARCK ND
58501-3908
US

IV. Provider business mailing address

805 N 5TH ST
BISMARCK ND
58501-3908
US

V. Phone/Fax

Practice location:
  • Phone: 701-258-1804
  • Fax:
Mailing address:
  • Phone: 701-258-1804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4112
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier4112
Identifier TypeOTHER
Identifier StateND
Identifier IssuerNORTH DAKOTA LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: