Provider Demographics
NPI:1679622039
Name:BEKKEDAHL, BRAD DOUGLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:DOUGLAS
Last Name:BEKKEDAHL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 2ND AVE W
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-3485
Mailing Address - Country:US
Mailing Address - Phone:701-774-3333
Mailing Address - Fax:701-572-8504
Practice Address - Street 1:2204 2ND AVE W
Practice Address - Street 2:SUITE 102
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-3485
Practice Address - Country:US
Practice Address - Phone:701-774-3333
Practice Address - Fax:701-572-8504
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND17261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice