Provider Demographics
NPI:1457769481
Name:JOHN SANDERSON
Entity Type:Organization
Organization Name:JOHN SANDERSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-584-2580
Mailing Address - Street 1:306 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:ND
Mailing Address - Zip Code:58533-7108
Mailing Address - Country:US
Mailing Address - Phone:701-584-2580
Mailing Address - Fax:
Practice Address - Street 1:306 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:ND
Practice Address - Zip Code:58533-7108
Practice Address - Country:US
Practice Address - Phone:701-584-2580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHN SANDERSON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1600122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty