Provider Demographics
NPI:1487882718
Name:PEDIATRIC DENTISTRY LTD
Entity type:Organization
Organization Name:PEDIATRIC DENTISTRY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-293-6999
Mailing Address - Street 1:1205 16TH AVE. SOUTH
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103
Mailing Address - Country:US
Mailing Address - Phone:701-293-6999
Mailing Address - Fax:701-235-2297
Practice Address - Street 1:1205 16TH AVE. SOUTH
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:701-293-6999
Practice Address - Fax:701-235-2297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2032122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty