Provider Demographics
NPI:1023483914
Name:BEULAH DENTAL PC
Entity type:Organization
Organization Name:BEULAH DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-873-2259
Mailing Address - Street 1:PO BOX 118
Mailing Address - Street 2:
Mailing Address - City:BEULAH
Mailing Address - State:ND
Mailing Address - Zip Code:58523-0118
Mailing Address - Country:US
Mailing Address - Phone:701-873-2259
Mailing Address - Fax:
Practice Address - Street 1:200 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BEULAH
Practice Address - State:ND
Practice Address - Zip Code:58523-6970
Practice Address - Country:US
Practice Address - Phone:701-873-2259
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1457382Medicaid