Provider Demographics
NPI:1104035252
Name:DWELLE, TERRY LYNN (MD, MPHTM)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:LYNN
Last Name:DWELLE
Suffix:
Gender:M
Credentials:MD, MPHTM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-3908
Mailing Address - Country:US
Mailing Address - Phone:701-258-1804
Mailing Address - Fax:
Practice Address - Street 1:805 N 5TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-3908
Practice Address - Country:US
Practice Address - Phone:701-258-1804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4112208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND4112OtherNORTH DAKOTA LICENSE