1101 Dental, PLLC

Primary specialty

DentistTaxonomy code 122300000X

License

2083 Issued in ND

Legal business name

1101 DENTAL, PLLC

Practice address

1101 S Columbia Rd
Unit B
Grand Forks, ND 58201-4055

Phone

(701) 795-1101

Fax

(701) 795-1102

NPI assigned

Mar 10, 2011

Organization subpart

No

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

Authorized official

Name

Heather Nichole Petricig, D.D.S.

Title

Owner/Dentist

Phone

(701) 795-1101

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

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

{
    "created_epoch": "1299715200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1299715200000",
    "number": "1750689030",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1101 S COLUMBIA RD",
            "address_2": "UNIT B",
            "city": "GRAND FORKS",
            "state": "ND",
            "postal_code": "582014055",
            "telephone_number": "701-795-1101",
            "fax_number": "701-795-1102"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1101 S COLUMBIA RD",
            "address_2": "UNIT B",
            "city": "GRAND FORKS",
            "state": "ND",
            "postal_code": "582014055",
            "telephone_number": "701-795-1101",
            "fax_number": "701-795-1102"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "1101 DENTAL, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-03-10",
        "last_updated": "2011-03-10",
        "status": "A",
        "authorized_official_last_name": "PETRICIG",
        "authorized_official_first_name": "HEATHER",
        "authorized_official_middle_name": "NICHOLE",
        "authorized_official_title_or_position": "OWNER/DENTIST",
        "authorized_official_telephone_number": "701-795-1101",
        "authorized_official_credential": "D.D.S."
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist",
            "state": "ND",
            "license": "2083",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "41566",
            "state": "ND"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Dentist in Grand Forks, ND
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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 10, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.