Healthcare Provider Details

I. General information

NPI: 1487105276
Provider Name (Legal Business Name): MAPLE FAMILY DENTAL P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

594 MAIN ST N
HORACE ND
58047-4640
US

IV. Provider business mailing address

594 MAIN ST N
HORACE ND
58047-4640
US

V. Phone/Fax

Practice location:
  • Phone: 701-552-6001
  • Fax:
Mailing address:
  • Phone: 701-552-6001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2046
License Number StateND

VIII. Authorized Official

Name: DR. JONATHAN BULTEMA
Title or Position: PRESIDENT
Credential: D.D.S
Phone: 701-552-6001