Provider Demographics
NPI:1902042609
Name:PATRICK LANDSIEDEL DDS PC
Entity Type:Organization
Organization Name:PATRICK LANDSIEDEL DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDSIEDEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-852-3222
Mailing Address - Street 1:1000 31ST AVE SW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-7403
Mailing Address - Country:US
Mailing Address - Phone:701-852-3222
Mailing Address - Fax:
Practice Address - Street 1:1000 31ST AVE SW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-7403
Practice Address - Country:US
Practice Address - Phone:701-852-3222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-30
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41062Medicaid