Provider Demographics
NPI:1285043802
Name:LIDGERWOOD DENTAL OFFICE
Entity Type:Organization
Organization Name:LIDGERWOOD DENTAL OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:MAROTZKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-538-4583
Mailing Address - Street 1:19 WILEY AVE S
Mailing Address - Street 2:
Mailing Address - City:LIDGERWOOD
Mailing Address - State:ND
Mailing Address - Zip Code:58053-0431
Mailing Address - Country:US
Mailing Address - Phone:701-538-4583
Mailing Address - Fax:701-538-4560
Practice Address - Street 1:19 WILEY AVE S
Practice Address - Street 2:
Practice Address - City:LIDGERWOOD
Practice Address - State:ND
Practice Address - Zip Code:58053-4001
Practice Address - Country:US
Practice Address - Phone:701-538-4583
Practice Address - Fax:701-538-4560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1488261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental