Healthcare Provider Details

I. General information

NPI: 1184716045
Provider Name (Legal Business Name): AGASSIZ DENTAL ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 04/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 ROBERTS AVE NE
COOPERSTOWN ND
58425
US

IV. Provider business mailing address

P.O. BOX 569
COOPERSTOWN ND
58425
US

V. Phone/Fax

Practice location:
  • Phone: 701-797-2641
  • Fax:
Mailing address:
  • Phone: 701-797-2641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1415
License Number StateND

VIII. Authorized Official

Name: MISS MELANIE J. HOYT
Title or Position: RECEPTIONIST/OFFICE MANAGER
Credential:
Phone: 701-797-2641