Healthcare Provider Details

I. General information

NPI: 1548558083
Provider Name (Legal Business Name): HIGH PLAINS DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2011
Last Update Date: 07/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

669 12TH ST W
DICKINSON ND
58601
US

IV. Provider business mailing address

669 12TH ST W
DICKINSON ND
58601-3554
US

V. Phone/Fax

Practice location:
  • Phone: 701-483-4746
  • Fax:
Mailing address:
  • Phone: 701-483-4746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberND2009
License Number StateND

VIII. Authorized Official

Name: MR. MARIA 'DUFFY' DORTHY MEYER
Title or Position: DENTIST
Credential: D.D.S
Phone: 701-483-4746