Provider Demographics
NPI:1144391632
Name:PRAIRIE ROSE FAMILY DENTISTS
Entity Type:Organization
Organization Name:PRAIRIE ROSE FAMILY DENTISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-223-1194
Mailing Address - Street 1:121 E FRONT AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-5589
Mailing Address - Country:US
Mailing Address - Phone:701-223-1194
Mailing Address - Fax:701-250-9614
Practice Address - Street 1:121 E FRONT AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5589
Practice Address - Country:US
Practice Address - Phone:701-223-1194
Practice Address - Fax:701-250-9614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41286Medicaid