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General NPI Number Information
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NPI Number | 1609302231
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Entity Type | Organization
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Legal Business Name | RIVERSIDE DENTAL PLLC
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Dates
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Enumeration Date | 05/02/2017
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Last Update Date | 05/02/2017
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Provider Practice Location Address
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Address Line | 1165 S COLUMBIA RD STE. B
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City | GRAND FORKS
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State | ND
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Zip | 58201-4007
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Country | US
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Telephone | 701-772-3544
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Fax | 701-772-3411
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Provider Business Mailing Address
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Address Line | 1165 S COLUMBIA RD STE. B
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City | GRAND FORKS
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State | ND
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Zip | 58201-4007
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Country | US
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Telephone | 701-772-3544
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Fax | 701-772-3411
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Authorized Official
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Title or Position | OWNER
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Name | DR. AMANDA VESTERSO
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Credential | DDS
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Telephone | 701-772-3544
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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 | 2037
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License Number State | ND
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