Healthcare Provider Details

I. General information

NPI: 1932361524
Provider Name (Legal Business Name): SELLE FAMILY DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 05/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 WESTERN DR
DICKINSON ND
58601-3155
US

IV. Provider business mailing address

1560 WESTERN DR
DICKINSON ND
58601-3155
US

V. Phone/Fax

Practice location:
  • Phone: 701-483-9801
  • Fax: 701-483-9803
Mailing address:
  • Phone: 701-483-9801
  • Fax: 701-483-9803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number1914
License Number StateND

VIII. Authorized Official

Name: MS. SHANNON SELLE
Title or Position: VICE PRESIDENT
Credential:
Phone: 701-483-9801