Provider Demographics
NPI:1184629651
Name:SELLE, BRENT JONATHON (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:JONATHON
Last Name:SELLE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 WESTERN DR
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-3155
Mailing Address - Country:US
Mailing Address - Phone:701-483-9801
Mailing Address - Fax:
Practice Address - Street 1:1560 WESTERN DR
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-3155
Practice Address - Country:US
Practice Address - Phone:701-483-9801
Practice Address - Fax:701-483-9803
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND19141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41288Medicaid
TXV01914OtherTEXAS BLUE CROSS BLUE SHI
ND01345827OtherTRICARE DENTAL INSURANCE
ND901914OtherBLUE CROSS BLUE SHIELD