Healthcare Provider Details

I. General information

NPI: 1598763120
Provider Name (Legal Business Name): PRAIRIE ORAL SURGERY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 07/21/2022
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2585 23RD AVE S STE A.
FARGO ND
58103
US

IV. Provider business mailing address

2585 23RD AVE S STE. A.
FARGO ND
58104
US

V. Phone/Fax

Practice location:
  • Phone: 701-478-4404
  • Fax: 701-478-4407
Mailing address:
  • Phone: 701-478-4404
  • Fax: 701-478-4407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MRS. BETH MARIE JAROSZEWSKI
Title or Position: FINANCE COORDINATOR
Credential:
Phone: 701-478-4404