Provider Demographics
NPI:1215465372
Name:AMUNDSON DENTAL ASSOCIATES
Entity type:Organization
Organization Name:AMUNDSON DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:AMUNDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-772-0171
Mailing Address - Street 1:2600 DEMERS AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4100
Mailing Address - Country:US
Mailing Address - Phone:701-772-0171
Mailing Address - Fax:701-772-3138
Practice Address - Street 1:2600 DEMERS AVE STE 107
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4100
Practice Address - Country:US
Practice Address - Phone:701-772-0171
Practice Address - Fax:701-772-3138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1781261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1437228095Medicaid