Healthcare Provider Details

I. General information

NPI: 1649816828
Provider Name (Legal Business Name): DR. JEREMIAH J. GLOSENGER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 12/21/2019
Certification Date: 12/21/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 ELK DR STE 3
MINOT ND
58701-1200
US

IV. Provider business mailing address

2615 ELK DR STE 3
MINOT ND
58701-1200
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JEREMIAH GLOSENGER
Title or Position: PRESIDENT
Credential: DDS, MS
Phone: 701-500-0476