Healthcare Provider Details

I. General information

NPI: 1184066425
Provider Name (Legal Business Name): DEREK DANNY WEIGAND D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2013
Last Update Date: 04/26/2021
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4302 13TH AVE S STE 10
FARGO ND
58103-3395
US

IV. Provider business mailing address

4302 13TH AVE S STE 10
FARGO ND
58103-3395
US

V. Phone/Fax

Practice location:
  • Phone: 701-281-8000
  • Fax:
Mailing address:
  • Phone: 701-281-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6034
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2396
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: