Christopher Paul Bothun, DDS
Individual provider Active NPI Dentist · Grand Forks, ND
NPI 1306374277 · NPPES record last updated Jul 21, 2022
Key facts
- NPI
- 1306374277
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 2312 (ND)
- Practice address
- 4000 17TH Ave S
Grand Forks, ND 58201-3905 - Phone
- (701) 775-0641
- NPI assigned
- May 23, 2017
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in ND
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20170703001841 | ND | Order and Referring Only - Dentist |
2264701408 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2312 | ND | MD | Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Dakota Dental Associates PC | Dentist | Past |
Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 2312 | ND | Yes |
Addresses
Primary practice location
4000 17TH Ave S
Grand Forks, ND 58201-3905
Mailing address
4000 17TH Ave S
Grand Forks, ND 58201-3905
Phone (701) 775-0641
Other providers in Grand Forks, ND
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 21, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.