Provider Demographics
NPI:1588838106
Name:PARKSIDE DENTAL PC
Entity Type:Organization
Organization Name:PARKSIDE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LOWELL
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHENEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:701-852-5333
Mailing Address - Street 1:701 3RD ST NE
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-2401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 3RD ST NE
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-2401
Practice Address - Country:US
Practice Address - Phone:701-852-5333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41332Medicaid