Provider Demographics
NPI:1992117501
Name:MISSOURI RIVER DENTAL, PC
Entity type:Organization
Organization Name:MISSOURI RIVER DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:ALWORTH
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-619-0917
Mailing Address - Street 1:1401 SKYLINE BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-1299
Mailing Address - Country:US
Mailing Address - Phone:701-751-7177
Mailing Address - Fax:701-751-7178
Practice Address - Street 1:1401 SKYLINE BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-1299
Practice Address - Country:US
Practice Address - Phone:701-751-7177
Practice Address - Fax:701-751-7178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-30
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND22141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty