Healthcare Provider Details

I. General information

NPI: 1568656114
Provider Name (Legal Business Name): APOLLONIA DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 08/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 BROWN AVENUE
MOTT ND
58646-0159
US

IV. Provider business mailing address

223 BROWN AVE
MOTT ND
58646-0159
US

V. Phone/Fax

Practice location:
  • Phone: 701-824-2991
  • Fax: 701-824-2750
Mailing address:
  • Phone: 701-824-2991
  • Fax: 701-824-2750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KRISTEN MANOLOVITS
Title or Position: PRESIDENT
Credential: DDS
Phone: 701-824-2991