Provider Demographics
NPI:1275944407
Name:DR DUANE KRIVARCHKA, DDS, PC
Entity Type:Organization
Organization Name:DR DUANE KRIVARCHKA, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-683-4455
Mailing Address - Street 1:PO BOX 233
Mailing Address - Street 2:11 11TH AVE W
Mailing Address - City:LISBON
Mailing Address - State:ND
Mailing Address - Zip Code:58054
Mailing Address - Country:US
Mailing Address - Phone:701-683-4455
Mailing Address - Fax:
Practice Address - Street 1:11 11TH AVE W
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054
Practice Address - Country:US
Practice Address - Phone:701-683-4455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-09
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1677261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND40908Medicaid