Provider Demographics
NPI:1366849549
Name:KORSMO FAMILY DENTISTRY, P.C.
Entity Type:Organization
Organization Name:KORSMO FAMILY DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:KORSMO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-775-0682
Mailing Address - Street 1:2401 S WASHINGTON ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6747
Mailing Address - Country:US
Mailing Address - Phone:701-775-0682
Mailing Address - Fax:
Practice Address - Street 1:2401 S WASHINGTON ST
Practice Address - Street 2:SUITE C
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6747
Practice Address - Country:US
Practice Address - Phone:701-775-0682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty