Provider Demographics
NPI:1023561123
Name:PINEHURST FAMILY DENTISTRY
Entity Type:Organization
Organization Name:PINEHURST FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:NEER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-223-1476
Mailing Address - Street 1:1001 W INTERSTATE AVE
Mailing Address - Street 2:STE 132
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0946
Mailing Address - Country:US
Mailing Address - Phone:701-223-1476
Mailing Address - Fax:701-223-4503
Practice Address - Street 1:1001 W INTERSTATE AVE
Practice Address - Street 2:STE 132
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0946
Practice Address - Country:US
Practice Address - Phone:701-223-1476
Practice Address - Fax:701-223-4503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1816261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1457770Medicaid