Provider Demographics
NPI:1225443310
Name:DAKOTA DENTAL CARE
Entity Type:Organization
Organization Name:DAKOTA DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CALEB
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-349-3636
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:ELLENDALE
Mailing Address - State:ND
Mailing Address - Zip Code:58436-0310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 MAIN STREET
Practice Address - Street 2:
Practice Address - City:ELLENDALE
Practice Address - State:ND
Practice Address - Zip Code:58436
Practice Address - Country:US
Practice Address - Phone:701-349-3636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-26
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1770122300000X
ND2229122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND040501Medicaid
SD7850030Medicaid