Healthcare Provider Details

I. General information

NPI: 1013472018
Provider Name (Legal Business Name): HAILY DATZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2019
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 18TH ST NW
MANDAN ND
58554-1612
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 701-667-5100
  • Fax: 701-667-5095
Mailing address:
  • Phone: 605-328-9419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24648
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: