Provider Demographics
NPI:1164677399
Name:KENMARE DENTAL CLINIC
Entity Type:Organization
Organization Name:KENMARE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:THELEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-385-4041
Mailing Address - Street 1:P.O. BOX 638
Mailing Address - Street 2:
Mailing Address - City:KENMARE
Mailing Address - State:ND
Mailing Address - Zip Code:58746-0638
Mailing Address - Country:US
Mailing Address - Phone:701-385-4041
Mailing Address - Fax:701-385-4986
Practice Address - Street 1:318 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:KENMARE
Practice Address - State:ND
Practice Address - Zip Code:58746-0638
Practice Address - Country:US
Practice Address - Phone:701-385-4041
Practice Address - Fax:701-385-4986
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENMARE DENTAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND17921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41118Medicaid