Healthcare Provider Details

I. General information

NPI: 1336051937
Provider Name (Legal Business Name): CHARLES MAKAKA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 7TH ST W
DICKINSON ND
58601-4335
US

IV. Provider business mailing address

2009 YELLOWSTONE CIR
DICKINSON ND
58601-3001
US

V. Phone/Fax

Practice location:
  • Phone: 701-402-3335
  • Fax:
Mailing address:
  • Phone: 701-402-3335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberNDL171125
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: