Provider Demographics
NPI:1285732313
Name:HETLAND, DENNIS LYNN (DDS)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:LYNN
Last Name:HETLAND
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 25TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-5900
Mailing Address - Country:US
Mailing Address - Phone:701-298-9400
Mailing Address - Fax:
Practice Address - Street 1:3525 25TH STREET SOUTH
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-5900
Practice Address - Country:US
Practice Address - Phone:701-298-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND17831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND6214690001Medicare NSC