Provider Demographics
NPI:1861497430
Name:SOURIS VALLEY DENTAL GROUP
Entity Type:Organization
Organization Name:SOURIS VALLEY DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:HILDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-852-5595
Mailing Address - Street 1:1300 37TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-7240
Mailing Address - Country:US
Mailing Address - Phone:701-852-5595
Mailing Address - Fax:701-852-2669
Practice Address - Street 1:1300 37TH AVE SW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-7240
Practice Address - Country:US
Practice Address - Phone:701-852-5595
Practice Address - Fax:701-852-2669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND15731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41311Medicaid
ND000980706OtherUNITED CONCORDIA