Provider Demographics
NPI:1093954570
Name:GREAT PLAINS PERIODONTICS, PC
Entity Type:Organization
Organization Name:GREAT PLAINS PERIODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:NEILS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-293-0577
Mailing Address - Street 1:2838 SOUTH UNIVERSITY DRIVE
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6030
Mailing Address - Country:US
Mailing Address - Phone:701-293-0577
Mailing Address - Fax:701-293-0910
Practice Address - Street 1:2838 SOUTH UNIVERSITY DRIVE
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6030
Practice Address - Country:US
Practice Address - Phone:701-293-0577
Practice Address - Fax:701-293-0910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-06
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND17861223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty