Basic Information
| Provider Information | |||||||||
| NPI: | 1720241615 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BELANGER | ||||||||
| FirstName: | MARTIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2010 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581220605 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1720 UNIVERSITY DR S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581034940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012804150 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2008 | ||||||||
| LastUpdateDate: | 12/29/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 57097 | CA | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 204E00000X | 2085 | ND | Y | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery | 204E00000X | D12849 | MN | N | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1720241615 | 05 | MN | MEDICAID | 41543 | 05 | ND | MEDICAID |