Provider Demographics
NPI:1043321334
Name:DERIK HOERNER, DDS, PC
Entity type:Organization
Organization Name:DERIK HOERNER, DDS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DERIK
Authorized Official - Middle Name:
Authorized Official - Last Name:HOERNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-955-5111
Mailing Address - Street 1:1004 S. 7TH STREET
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-6531
Mailing Address - Country:US
Mailing Address - Phone:701-390-1920
Mailing Address - Fax:701-255-4055
Practice Address - Street 1:1004 S. 7TH STREET
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-6531
Practice Address - Country:US
Practice Address - Phone:701-390-1920
Practice Address - Fax:701-255-4055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2057122300000X
ND13871223G0001X
ND14271223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1427OtherSTATE DENTAL LICENSE #
ND40424Medicaid
ND41463Medicaid
ND2030OtherNDBOE NUMBER
ND40644Medicaid
ND1387OtherSTATE DENTAL #
ND2057OtherNDBOE NUMBER
ND40642Medicaid
ND41498Medicaid
ND40424Medicaid