=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992107122
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAKOTA DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2014
-----------------------------------------------------
Last Update Date | 06/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2605 19TH AVE W SUITE 102
-----------------------------------------------------
City | WILLISTON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58801-2892
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-577-3333
-----------------------------------------------------
Fax | 701-577-3336
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2605 19TH AVE W SUITE 102
-----------------------------------------------------
City | WILLISTON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58801-2892
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-577-3333
-----------------------------------------------------
Fax | 701-577-3336
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. STEVEN BLACKHURST
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 701-577-3333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 2209
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 2208
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 2210
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------