Provider Demographics
NPI:1942219852
Name:DANIEL L. MENGEDOTH, DDS LTD
Entity Type:Organization
Organization Name:DANIEL L. MENGEDOTH, DDS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:MENGEDOTH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-236-7076
Mailing Address - Street 1:2121 HIGHWAY 10 E
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-2559
Mailing Address - Country:US
Mailing Address - Phone:218-236-7076
Mailing Address - Fax:218-236-4999
Practice Address - Street 1:2121 HIGHWAY 10 E
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-2559
Practice Address - Country:US
Practice Address - Phone:218-236-7076
Practice Address - Fax:218-236-4999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND111851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty