Provider Demographics
NPI:1639539794
Name:WEST-ROEHL, MEDORA CAROLINE (DMD)
Entity Type:Individual
Prefix:
First Name:MEDORA
Middle Name:CAROLINE
Last Name:WEST-ROEHL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3285 FIECHTNER DR S STE C
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2490
Mailing Address - Country:US
Mailing Address - Phone:701-238-8513
Mailing Address - Fax:
Practice Address - Street 1:3285 FIECHTNER DR S STE C
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2490
Practice Address - Country:US
Practice Address - Phone:701-238-8513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-02
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDIN PROCESS 6-13-161223G0001X
ND2285122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice