Provider Demographics
NPI:1598763120
Name:PRAIRIE ORAL SURGERY LTD
Entity Type:Organization
Organization Name:PRAIRIE ORAL SURGERY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JAROSZEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-478-4404
Mailing Address - Street 1:2585 23RD AVE S
Mailing Address - Street 2:STE. A.
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104
Mailing Address - Country:US
Mailing Address - Phone:701-478-4404
Mailing Address - Fax:701-478-4407
Practice Address - Street 1:2585 23RD AVE S
Practice Address - Street 2:STE A.
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:701-478-4404
Practice Address - Fax:701-478-4407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1223S0112X
1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41305Medicaid