Provider Demographics
NPI:1205042439
Name:DEETER, NATHAN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:MICHAEL
Last Name:DEETER
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 1:2004 GRIMSRUD DR
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1316
Mailing Address - Country:US
Mailing Address - Phone:701-371-9954
Mailing Address - Fax:
Practice Address - Street 1:1003 GATEWAY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0508
Practice Address - Country:US
Practice Address - Phone:701-222-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND20131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice