=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942579081
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRAIRIE DENTAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2011
-----------------------------------------------------
Last Update Date | 12/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 608 HIGHWAY 12 W
-----------------------------------------------------
City | BOWMAN
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58623-4507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-523-3255
-----------------------------------------------------
Fax | 701-523-5742
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 710
-----------------------------------------------------
City | BOWMAN
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58623-0710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-523-3255
-----------------------------------------------------
Fax | 701-523-5742
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | JENNIFER SARSLAND
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 701-523-3255
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 126800000X
-----------------------------------------------------
Taxonomy Name | Dental Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2101
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------