Healthcare Provider Details

I. General information

NPI: 1649338377
Provider Name (Legal Business Name): BRIDGING THE DENTAL GAP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1223 S 12TH ST STE 1
BISMARCK ND
58504
US

IV. Provider business mailing address

1223 S 12TH ST STE 1 BRIDGING THE DENTAL GAP INC
BISMARCK ND
58504
US

V. Phone/Fax

Practice location:
  • Phone: 701-221-0518
  • Fax: 701-221-0537
Mailing address:
  • Phone: 701-221-0518
  • Fax: 701-221-0537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARCIA A OLSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 701-221-0518