=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437870979
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALTHOFF DENTAL, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2022
-----------------------------------------------------
Last Update Date | 09/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3210 18TH ST S STE A
-----------------------------------------------------
City | FARGO
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58104-6789
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-729-1327
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3210 18TH ST S STE A
-----------------------------------------------------
City | FARGO
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58104-6789
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-729-1327
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SUSAN ALTHOFF
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 701-729-1327
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------