Healthcare Provider Details

I. General information

NPI: 1982411401
Provider Name (Legal Business Name): VICTOR ISAIAH MASTLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2024
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ELM ST N
FARGO ND
58102-2417
US

IV. Provider business mailing address

2915 BLUESTEM DR APT 1158
WEST FARGO ND
58078-8027
US

V. Phone/Fax

Practice location:
  • Phone: 775-895-5667
  • Fax:
Mailing address:
  • Phone: 775-895-5667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number2010
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: