Healthcare Provider Details

I. General information

NPI: 1144874108
Provider Name (Legal Business Name): SARAH RUTH CAVANAUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2019
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3883 74TH AVE NE
FORT TOTTEN ND
58335
US

IV. Provider business mailing address

PO BOX 23
SAINT MICHAEL ND
58370-0023
US

V. Phone/Fax

Practice location:
  • Phone: 701-766-1615
  • Fax:
Mailing address:
  • Phone: 701-351-6384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number2385
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2385
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2385
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: