Healthcare Provider Details

I. General information

NPI: 1235695958
Provider Name (Legal Business Name): BIG BEAR DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2019
Last Update Date: 02/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 ELK DR STE 1
MINOT ND
58701-1200
US

IV. Provider business mailing address

17 SCRAMBLE ST
MINOT ND
58701-7495
US

V. Phone/Fax

Practice location:
  • Phone: 701-839-4440
  • Fax:
Mailing address:
  • Phone: 319-431-4015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: TAYLOR ZMOOS
Title or Position: PRESIDENT
Credential: DDS
Phone: 319-431-4015