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General NPI Number Information
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NPI Number | 1013326768
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Entity Type | Organization
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Legal Business Name | GARY CORNFORTH
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Dates
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Enumeration Date | 08/07/2014
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Last Update Date | 08/07/2014
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Provider Practice Location Address
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Address Line | 2534 UNIVERSITY DR S SUITE #6
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City | FARGO
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State | ND
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Zip | 58103-5700
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Country | US
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Telephone | 701-232-1500
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Fax | 701-293-6969
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Provider Business Mailing Address
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Address Line | 2534 UNIVERSITY DR S SUITE #6
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City | FARGO
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State | ND
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Zip | 58103-5700
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Country | US
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Telephone | 701-232-1500
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Fax | 701-293-6969
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Authorized Official
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Title or Position | ORTHODONTIST
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Name | GARY CORNFORTH
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Credential | DDS MS
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Telephone | 701-232-1500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 1504C
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License Number State | ND
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