Provider Demographics
NPI:1659399517
Name:HEARTLAND DENTAL
Entity Type:Organization
Organization Name:HEARTLAND DENTAL
Other - Org Name:EVERGREEN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:FINES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-237-6307
Mailing Address - Street 1:1213 19TH AVE N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-2242
Mailing Address - Country:US
Mailing Address - Phone:701-237-6307
Mailing Address - Fax:
Practice Address - Street 1:1213 19TH AVE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2242
Practice Address - Country:US
Practice Address - Phone:701-237-6307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND19491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty