Healthcare Provider Details

I. General information

NPI: 1245869858
Provider Name (Legal Business Name): GRANT EDLAND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 4TH AVE NE
WATFORD CITY ND
58854-7628
US

IV. Provider business mailing address

709 4TH AVE NE
WATFORD CITY ND
58854-7628
US

V. Phone/Fax

Practice location:
  • Phone: 701-842-3000
  • Fax: 701-842-6248
Mailing address:
  • Phone: 701-842-3000
  • Fax: 701-842-6248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number036.165111
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: