Provider Demographics
NPI:1225505761
Name:BLAKE RISTVEDT DENTAL PLLC
Entity Type:Organization
Organization Name:BLAKE RISTVEDT DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:E
Authorized Official - Last Name:RISTVEDT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-866-3676
Mailing Address - Street 1:520 MAIN AVE STE 705
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1967
Mailing Address - Country:US
Mailing Address - Phone:701-237-4341
Mailing Address - Fax:701-297-5938
Practice Address - Street 1:520 MAIN AVE STE 705
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1967
Practice Address - Country:US
Practice Address - Phone:701-237-4341
Practice Address - Fax:701-297-5938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty