Healthcare Provider Details

I. General information

NPI: 1366774994
Provider Name (Legal Business Name): DR KENNETH MCDOUGALL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2010
Last Update Date: 02/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 1ST AVE S
JAMESTOWN ND
58401-4746
US

IV. Provider business mailing address

815 1ST AVE S
JAMESTOWN ND
58401-4746
US

V. Phone/Fax

Practice location:
  • Phone: 701-251-2240
  • Fax: 701-952-9487
Mailing address:
  • Phone: 701-251-2240
  • Fax: 701-952-9487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number1668
License Number StateND

VIII. Authorized Official

Name: DR. KENNETH DALE MCDOUGALL
Title or Position: PRESIDENT
Credential: DDS
Phone: 701-251-2240