Healthcare Provider Details

I. General information

NPI: 1952044968
Provider Name (Legal Business Name): MODERN ESTHETICS & DERMATOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 THOMPSON ST STE 1
BOTTINEAU ND
58318-1238
US

IV. Provider business mailing address

322 5TH ST E
BOTTINEAU ND
58318-1402
US

V. Phone/Fax

Practice location:
  • Phone: 701-201-0636
  • Fax:
Mailing address:
  • Phone: 701-201-0636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MOLLY BEYER
Title or Position: NURSE PRACTITIONER, OWNER
Credential: NP
Phone: 701-201-0636