Provider Demographics
NPI:1992107122
Name:DAKOTA DENTAL
Entity type:Organization
Organization Name:DAKOTA DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKHURST
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:701-577-3333
Mailing Address - Street 1:2605 19TH AVE W
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-2892
Mailing Address - Country:US
Mailing Address - Phone:701-577-3333
Mailing Address - Fax:701-577-3336
Practice Address - Street 1:2605 19TH AVE W
Practice Address - Street 2:SUITE 102
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-2892
Practice Address - Country:US
Practice Address - Phone:701-577-3333
Practice Address - Fax:701-577-3336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-18
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2210261QD0000X
ND2209261QD0000X
NC2208261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental