Healthcare Provider Details

I. General information

NPI: 1679622039
Provider Name (Legal Business Name): BRAD DOUGLAS BEKKEDAHL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 2ND AVE W SUITE 102
WILLISTON ND
58801-3485
US

IV. Provider business mailing address

2204 2ND AVE W SUITE 102
WILLISTON ND
58801-3485
US

V. Phone/Fax

Practice location:
  • Phone: 701-774-3333
  • Fax: 701-572-8504
Mailing address:
  • Phone: 701-774-3333
  • Fax: 701-572-8504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1726
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: