Provider Demographics
NPI:1487824991
Name:DAKOTA PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:DAKOTA PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:HOGE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-478-5439
Mailing Address - Street 1:4265 45TH ST S STE 202
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4309
Mailing Address - Country:US
Mailing Address - Phone:701-478-5439
Mailing Address - Fax:701-364-5440
Practice Address - Street 1:4265 45TH ST S STE 202
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4309
Practice Address - Country:US
Practice Address - Phone:701-478-5439
Practice Address - Fax:701-364-5440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND19981223G0001X
ND20001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41438Medicaid