Healthcare Provider Details

I. General information

NPI: 1093190829
Provider Name (Legal Business Name): EATON DENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2015
Last Update Date: 11/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1338 GATEWAY DR S
FARGO ND
58103-3512
US

IV. Provider business mailing address

1338 GATEWAY DR S
FARGO ND
58103-3512
US

V. Phone/Fax

Practice location:
  • Phone: 701-232-1664
  • Fax:
Mailing address:
  • Phone: 701-232-1664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2247
License Number StateND

VIII. Authorized Official

Name: DR. MEGHAN MARIE SMITH
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 701-232-1664