Provider Demographics
NPI:1417062969
Name:DITCH, DAVID MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:DITCH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 342
Mailing Address - Street 2:
Mailing Address - City:PELICAN RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56572
Mailing Address - Country:US
Mailing Address - Phone:218-863-5858
Mailing Address - Fax:218-863-1143
Practice Address - Street 1:28 E MILL ST
Practice Address - Street 2:
Practice Address - City:PELICAN RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56572
Practice Address - Country:US
Practice Address - Phone:218-863-5858
Practice Address - Fax:218-863-1143
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND103761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice