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General NPI Number Information
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NPI Number | 1225204704
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Entity Type | Organization
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Legal Business Name | NORTH COUNTRY DENTAL SERVICE
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Dates
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Enumeration Date | 05/05/2008
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Last Update Date | 08/17/2009
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Provider Practice Location Address
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Address Line | 1311 BEMIDJI AVE N
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City | BEMIDJI
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State | MN
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Zip | 56601-3811
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Country | US
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Telephone | 218-751-1111
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Fax | 218-444-6318
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Provider Business Mailing Address
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Address Line | 1311 BEMIDJI AVE N P.O. BOX 1310
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City | BEMIDJI
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State | MN
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Zip | 56601-3811
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Country | US
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Telephone | 218-751-1111
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. JOHN E. LUETH
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Credential | D.D.S.
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Telephone | 218-751-1111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 9539
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License Number State | MN
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