=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891090668
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IDEAL IMAGE DENTISTRY & SPA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2011
-----------------------------------------------------
Last Update Date | 01/25/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1008 E MAIN ST
-----------------------------------------------------
City | MANDAN
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58554-3762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-667-1933
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1008 E MAIN ST
-----------------------------------------------------
City | MANDAN
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58554-3762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-667-1933
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. FREDRICK A LANDGREBE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 701-667-1933
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 1593
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------