Healthcare Provider Details

I. General information

NPI: 1104863505
Provider Name (Legal Business Name): FACE AND JAW SURGEONS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 06/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 ELK DR SUITE 3
MINOT ND
58701-1200
US

IV. Provider business mailing address

2615 ELK DR SUITE 3
MINOT ND
58701-1200
US

V. Phone/Fax

Practice location:
  • Phone: 701-852-3421
  • Fax: 701-838-1842
Mailing address:
  • Phone: 701-852-3421
  • Fax: 701-838-1842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH R DEATHERAGE
Title or Position: DMD MD
Credential: DMD MD
Phone: 701-258-7220