=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508374497
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAKOTA DENTAL CENTER, P.L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2018
-----------------------------------------------------
Last Update Date | 01/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 1ST AVE SW
-----------------------------------------------------
City | BOWMAN
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58623-4213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-523-5651
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX E
-----------------------------------------------------
City | BOWMAN
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58623-0119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/DENTIST
-----------------------------------------------------
Name | DR. CAITLIN C JACQUOT
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 701-523-5651
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 2291
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------