Healthcare Provider Details

I. General information

NPI: 1568146892
Provider Name (Legal Business Name): KENNER FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 5TH AVE SE
DEVILS LAKE ND
58301-3621
US

IV. Provider business mailing address

PO BOX 220
DEVILS LAKE ND
58301-0220
US

V. Phone/Fax

Practice location:
  • Phone: 701-662-4141
  • Fax:
Mailing address:
  • Phone: 701-662-4141
  • Fax:

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: SARAH CAVANAUGH
Title or Position: DENTIST
Credential: DDS
Phone: 701-662-4141