Provider Demographics
NPI:1033540539
Name:MENGEDOTH, DANIEL LAWRENCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:LAWRENCE
Last Name:MENGEDOTH
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 1:2585 23RD AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103
Mailing Address - Country:US
Mailing Address - Phone:701-356-1280
Mailing Address - Fax:701-356-1281
Practice Address - Street 1:2585 23RD AVE S
Practice Address - Street 2:SUITE C
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6172
Practice Address - Country:US
Practice Address - Phone:701-356-1280
Practice Address - Fax:701-356-1281
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND20871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice