Provider Demographics
NPI:1609302231
Name:RIVERSIDE DENTAL PLLC
Entity Type:Organization
Organization Name:RIVERSIDE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:VESTERSO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-772-3544
Mailing Address - Street 1:1165 S COLUMBIA RD
Mailing Address - Street 2:STE. B
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4007
Mailing Address - Country:US
Mailing Address - Phone:701-772-3544
Mailing Address - Fax:701-772-3411
Practice Address - Street 1:1165 S COLUMBIA RD
Practice Address - Street 2:STE. B
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4007
Practice Address - Country:US
Practice Address - Phone:701-772-3544
Practice Address - Fax:701-772-3411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2037122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty