Provider Demographics
NPI:1104863505
Name:FACE AND JAW SURGEONS PC
Entity Type:Organization
Organization Name:FACE AND JAW SURGEONS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DMD MD
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:DEATHERAGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MD
Authorized Official - Phone:701-258-7220
Mailing Address - Street 1:2615 ELK DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-1200
Mailing Address - Country:US
Mailing Address - Phone:701-852-3421
Mailing Address - Fax:701-838-1842
Practice Address - Street 1:2615 ELK DR
Practice Address - Street 2:SUITE 3
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-1200
Practice Address - Country:US
Practice Address - Phone:701-852-3421
Practice Address - Fax:701-838-1842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41328Medicaid
N70243Medicare PIN