Healthcare Provider Details

I. General information

NPI: 1114013604
Provider Name (Legal Business Name): THEODORE A BROWN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 3RD AVE SE
MOHALL ND
58761
US

IV. Provider business mailing address

P.O. BOX 188
MOHALL ND
58761-0188
US

V. Phone/Fax

Practice location:
  • Phone: 701-756-6655
  • Fax:
Mailing address:
  • Phone: 701-756-6655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1760
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: