MEDICARE: NORTHCREEK DENTAL, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	1893	ND

General Provider Information

NPI Number	:	1902203854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHCREEK DENTAL, PC

Provider Business Mailing Address
First Line	:	PO BOX 417
Second Line	:
City	:	HANKINSON
State	:	ND
Zip	:	58041-0417
Country	:	US
Telephone Number	:	701-242-7140
Fax Number	:	701-242-7091

Provider Business Practice Location Address
First Line	:	333 MAIN AVE S
Second Line	:
City	:	HANKINSON
State	:	ND
Zip	:	58041-4100
Country	:	US
Telephone Number	:	701-242-7140
Fax Number	:	701-242-7091

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	MRS. DAWN M SCHAFFER
Credential	:	RDH
Telephone Number	:	701-242-7140

Provider Enumeration Date	:	11/20/2014
Last Update Date	:	11/20/2014

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