Healthcare Provider Details

I. General information

NPI: 1689503930
Provider Name (Legal Business Name): DYLAN ELLETSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 E MAIN ST
MANDAN ND
58554-3821
US

IV. Provider business mailing address

1810 E MAIN ST
MANDAN ND
58554-3821
US

V. Phone/Fax

Practice location:
  • Phone: 701-415-0000
  • Fax:
Mailing address:
  • Phone: 701-415-0000
  • Fax: 833-969-0195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2871
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: