Healthcare Provider Details

I. General information

NPI: 1578898268
Provider Name (Legal Business Name): DAKOTA PEDIATRIC DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2009
Last Update Date: 10/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2812 17TH AVE S SUITE F
GRAND FORKS ND
58201-4048
US

IV. Provider business mailing address

2812 17TH AVE S SUITE F
GRAND FORKS ND
58201-4048
US

V. Phone/Fax

Practice location:
  • Phone: 701-746-1400
  • Fax:
Mailing address:
  • Phone: 701-746-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2000
License Number StateND

VIII. Authorized Official

Name: DR. CHAD JAMES HOGE
Title or Position: VICE PRESIDENT
Credential: DDS
Phone: 701-200-5771