Provider Demographics
NPI:1992914055
Name:FARGO FAMILY DENTISTRY PC
Entity type:Organization
Organization Name:FARGO FAMILY DENTISTRY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-237-6008
Mailing Address - Street 1:3210 18TH ST SO
Mailing Address - Street 2:SUITE B
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104
Mailing Address - Country:US
Mailing Address - Phone:701-237-6008
Mailing Address - Fax:701-893-3017
Practice Address - Street 1:3210 18TH ST SO
Practice Address - Street 2:SUITE B
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104
Practice Address - Country:US
Practice Address - Phone:701-237-6008
Practice Address - Fax:701-893-3017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1879 ND122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty