Provider Demographics
NPI:1174666119
Name:PARK RIVER DENTAL, PC
Entity Type:Organization
Organization Name:PARK RIVER DENTAL, PC
Other - Org Name:PARK RIVER DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-284-6131
Mailing Address - Street 1:PO BOX 662
Mailing Address - Street 2:
Mailing Address - City:PARK RIVER
Mailing Address - State:ND
Mailing Address - Zip Code:58270-0662
Mailing Address - Country:US
Mailing Address - Phone:701-284-6131
Mailing Address - Fax:
Practice Address - Street 1:418 BRIGGS AVENUE
Practice Address - Street 2:
Practice Address - City:PARK RIVER
Practice Address - State:ND
Practice Address - Zip Code:58270-0662
Practice Address - Country:US
Practice Address - Phone:701-284-6131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND18051223G0001X
ND13551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty