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General NPI Number Information
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NPI Number | 1841258837
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Entity Type | Organization
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Legal Business Name | FAMILY DENTISTRY OF MOORHEAD, LTD.
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Dates
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Enumeration Date | 05/02/2006
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Last Update Date | 06/26/2014
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Provider Practice Location Address
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Address Line | 1616 30TH AVE S
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City | MOORHEAD
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State | MN
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Zip | 56560-5152
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Country | US
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Telephone | 218-233-4267
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Fax |
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Provider Business Mailing Address
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Address Line | 1616 30TH AVE S
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City | MOORHEAD
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State | MN
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Zip | 56560-5152
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Country | US
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Telephone | 218-233-4267
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Fax |
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Authorized Official
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Title or Position | OWNER/DDS
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Name | MR. CHRISTOPHER MARK MATHISON
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Credential | DDS
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Telephone | 218-233-4267
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 9145
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License Number State | MN
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