Healthcare Provider Details

I. General information

NPI: 1336170265
Provider Name (Legal Business Name): DENNIS G SOLLOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 UNIVERSITY DR S
FARGO ND
58103-4940
US

IV. Provider business mailing address

PO BOX 6001
FARGO ND
58108-6001
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-3300
  • Fax: 701-364-8906
Mailing address:
  • Phone: 701-364-3300
  • Fax: 701-364-8906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number5279
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier681203100
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 2
Identifier126895
Identifier TypeOTHER
Identifier StateND
Identifier IssuerUCARE #
# 3
Identifier911595
Identifier TypeOTHER
Identifier StateND
Identifier IssuerAMERICA'S PPO/ARAZ #
# 4
IdentifierHP25769
Identifier TypeOTHER
Identifier StateND
Identifier IssuerHEALTHPARTNERS #
# 5
IdentifierND200062
Identifier TypeOTHER
Identifier StateND
Identifier IssuerLHS #
# 6
Identifier2300159
Identifier TypeOTHER
Identifier StateND
Identifier IssuerMEDICA #
# 7
Identifier15146
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 8
Identifier2300113
Identifier TypeOTHER
Identifier StateND
Identifier IssuerMEDICA #
# 9
IdentifierDA9011015590
Identifier TypeOTHER
Identifier StateND
Identifier IssuerPREFERRED ONE #
# 10
Identifier16583SO
Identifier TypeOTHER
Identifier StateND
Identifier IssuerMNBS #
# 11
Identifier2222
Identifier TypeOTHER
Identifier StateND
Identifier IssuerNDBS #

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: