Provider Demographics
NPI:1932642790
Name:HETLAND EAR NOSE THROAT PC
Entity Type:Organization
Organization Name:HETLAND EAR NOSE THROAT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:HETLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-934-1393
Mailing Address - Street 1:2331 TYLER PKWY STE 6
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0871
Mailing Address - Country:US
Mailing Address - Phone:701-258-6851
Mailing Address - Fax:701-258-6852
Practice Address - Street 1:2331 TYLER PKWY STE 6
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0871
Practice Address - Country:US
Practice Address - Phone:701-258-6851
Practice Address - Fax:701-258-6852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND11581207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1457302622OtherPROVIDER NPI