Healthcare Provider Details

I. General information

NPI: 1942579081
Provider Name (Legal Business Name): PRAIRIE DENTAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 HIGHWAY 12 W
BOWMAN ND
58623-4507
US

IV. Provider business mailing address

PO BOX 710
BOWMAN ND
58623-0710
US

V. Phone/Fax

Practice location:
  • Phone: 701-523-3255
  • Fax: 701-523-5742
Mailing address:
  • Phone: 701-523-3255
  • Fax: 701-523-5742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2101
License Number StateND

VIII. Authorized Official

Name: JENNIFER SARSLAND
Title or Position: DENTIST
Credential: DDS
Phone: 701-523-3255