Healthcare Provider Details

I. General information

NPI: 1396151569
Provider Name (Legal Business Name): RICHARD L. CALLENDER, DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 07/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 1ST ST
WEST FARGO ND
58078-1835
US

IV. Provider business mailing address

120 1ST ST
WEST FARGO ND
58078-1835
US

V. Phone/Fax

Practice location:
  • Phone: 701-282-5930
  • Fax: 701-282-0017
Mailing address:
  • Phone: 701-282-5930
  • Fax: 701-282-0017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1509
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00040519
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name: RICHARD L CALLENDER
Title or Position: DENTIST, PERSONAL CORPORATION
Credential: DDS
Phone: 701-282-5930