Basic Information
Provider Information
NPI: 1548558083
EntityType: 2
ReplacementNPI:  
OrganizationName: HIGH PLAINS DENTAL
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 669 12TH ST W
Address2:  
City: DICKINSON
State: ND
PostalCode: 586013554
CountryCode: US
TelephoneNumber: 7014834746
FaxNumber:  
Practice Location
Address1: 669 12TH ST W
Address2:  
City: DICKINSON
State: ND
PostalCode: 58601
CountryCode: US
TelephoneNumber: 7014834746
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/19/2011
LastUpdateDate: 07/19/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: MEYER
AuthorizedOfficialFirstName: MARIA 'DUFFY'
AuthorizedOfficialMiddleName: DORTHY
AuthorizedOfficialTitleorPosition: DENTIST
AuthorizedOfficialTelephone: 7014834746
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: D.D.S
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001XND2009NDY193400000X SINGLE SPECIALTY GROUPDental ProvidersDentistGeneral Practice

No ID Information.


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