NPIMap

Organization Active NPI

Face and Jaw Surgeons PC

  • Oral and Maxillofacial Surgery (Dentist)
  • Bismarck, ND
National Provider Identifier
1184667305
Registry record updated Apr 25, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X
Legal business name
FACE AND JAW SURGEONS PC
Practice address
1140 W Capitol Ave
Bismarck, ND 58501-9956
Phone
(701) 258-7220
Fax
(701) 222-2329
NPI assigned
Jun 14, 2006
Last updated
Apr 25, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 25, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Joseph R Deatherage, DMD MDNPI 1003859117
Title
DMD MD
Phone
(701) 258-7220

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Oral and Maxillofacial Surgery (Dentist) 1223S0112X NU Primary

Addresses

Primary practice location

1140 W Capitol Ave
Bismarck, ND 58501-9956

Mailing address

1730 Burnt Boat Dr Ste 300
Bismarck, ND 58503-0886
Phone (701) 258-7220

Other identifiers 1

IdentifierTypeStateIssuer
41124MedicaidND

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ND

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040514000837 ND Part B Supplier - Clinic/Group Practice 1153311881 Receives reassigned benefits from 14 practitioners
5 other NPIs on this enrollment
Practice locations: Jamestown, ND; Dickinson, ND; Grand Forks, ND; Bismarck, ND; Fargo, ND

Other NPIs on the same Medicare enrollment 5

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Face Jaw Surgeons PC5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1140 W Capitol Ave
Bismarck, ND 58501
Phone (701) 258-7220

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150243200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1556150400000",
    "number": "1184667305",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1730 BURNT BOAT DR STE 300",
            "city": "BISMARCK",
            "state": "ND",
            "postal_code": "585030886",
            "telephone_number": "701-258-7220",
            "fax_number": "701-222-2329"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1140 W CAPITOL AVE",
            "city": "BISMARCK",
            "state": "ND",
            "postal_code": "585019956",
            "telephone_number": "701-258-7220",
            "fax_number": "701-222-2329"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FACE AND JAW SURGEONS PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-14",
        "last_updated": "2019-04-25",
        "status": "A",
        "authorized_official_last_name": "DEATHERAGE",
        "authorized_official_first_name": "JOSEPH",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "DMD MD",
        "authorized_official_telephone_number": "701-258-7220",
        "authorized_official_credential": "DMD MD"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "41124",
            "state": "ND"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Bismarck, ND

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 25, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.