Provider Demographics
NPI:1144874108
Name:CAVANAUGH, SARAH RUTH
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:RUTH
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:ND
Mailing Address - Zip Code:58370-0023
Mailing Address - Country:US
Mailing Address - Phone:701-351-6384
Mailing Address - Fax:
Practice Address - Street 1:3883 74TH AVE NE
Practice Address - Street 2:
Practice Address - City:FORT TOTTEN
Practice Address - State:ND
Practice Address - Zip Code:58335
Practice Address - Country:US
Practice Address - Phone:701-766-1615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-29
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND23851223D0001X, 1223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health
No1223G0001XDental ProvidersDentistGeneral Practice