Provider Demographics
NPI:1619355484
Name:FARGO MOORHEAD DENTAL & DENTURES P C
Entity Type:Organization
Organization Name:FARGO MOORHEAD DENTAL & DENTURES P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEVIN
Authorized Official - Middle Name:WALKER
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-281-8000
Mailing Address - Street 1:4302 13TH AVE S
Mailing Address - Street 2:SUITE 10
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3395
Mailing Address - Country:US
Mailing Address - Phone:701-281-8000
Mailing Address - Fax:
Practice Address - Street 1:4302 13TH AVE S
Practice Address - Street 2:SUITE 10
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3395
Practice Address - Country:US
Practice Address - Phone:701-281-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty