Provider Demographics
NPI:1376763839
Name:OTTO W. DOHM, DDS, MS, PC
Entity Type:Organization
Organization Name:OTTO W. DOHM, DDS, MS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OTTO
Authorized Official - Middle Name:W
Authorized Official - Last Name:DOHM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:701-222-8760
Mailing Address - Street 1:1142 W CAPITOL AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1306
Mailing Address - Country:US
Mailing Address - Phone:701-222-8760
Mailing Address - Fax:701-222-3162
Practice Address - Street 1:1142 W CAPITOL AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1306
Practice Address - Country:US
Practice Address - Phone:701-222-8760
Practice Address - Fax:701-222-3162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND17661223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41031Medicaid
ND41031Medicaid