Healthcare Provider Details

I. General information

NPI: 1285043802
Provider Name (Legal Business Name): LIDGERWOOD DENTAL OFFICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2014
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 WILEY AVE S
LIDGERWOOD ND
58053-4001
US

IV. Provider business mailing address

19 WILEY AVE S
LIDGERWOOD ND
58053-0431
US

V. Phone/Fax

Practice location:
  • Phone: 701-538-4583
  • Fax: 701-538-4560
Mailing address:
  • Phone: 701-538-4583
  • Fax: 701-538-4560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number1488
License Number StateND

VIII. Authorized Official

Name: DR. JAMES D MAROTZKE
Title or Position: OWNER
Credential: DDS
Phone: 701-538-4583