Healthcare Provider Details

I. General information

NPI: 1003769779
Provider Name (Legal Business Name): ETHAN OFTEDAHL
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2026
Last Update Date: 02/20/2026
Certification Date: 02/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 2ND AVE S
FARGO ND
58103-1705
US

IV. Provider business mailing address

921 2ND AVE S
FARGO ND
58103-1705
US

V. Phone/Fax

Practice location:
  • Phone: 701-361-9922
  • Fax: 701-829-7140
Mailing address:
  • Phone: 701-361-9922
  • Fax: 701-829-7140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number837
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: