Healthcare Provider Details

I. General information

NPI: 1073814497
Provider Name (Legal Business Name): STACEY ANN SELL RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2010
Last Update Date: 11/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 9TH AVE S
FARGO ND
58103-8712
US

IV. Provider business mailing address

2701 9TH AVE S
FARGO ND
58103-8712
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-9990
  • Fax: 701-364-9992
Mailing address:
  • Phone: 701-364-9990
  • Fax: 701-364-9992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number761
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: