Provider Demographics
NPI:1437334380
Name:BRIDGE CITY DENTISTRY P.C.
Entity Type:Organization
Organization Name:BRIDGE CITY DENTISTRY P.C.
Other - Org Name:DENTAL ASSOCIATES OF VALLEY CITY P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CARON
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-845-4221
Mailing Address - Street 1:202 CENTRAL AVE S
Mailing Address - Street 2:
Mailing Address - City:VALLEY CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58072-3325
Mailing Address - Country:US
Mailing Address - Phone:701-845-4221
Mailing Address - Fax:
Practice Address - Street 1:239 2ND AVE NW
Practice Address - Street 2:
Practice Address - City:VALLEY CITY
Practice Address - State:ND
Practice Address - Zip Code:58072-2909
Practice Address - Country:US
Practice Address - Phone:701-845-4221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND19961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1053510982Medicaid
ND1073681953Medicaid