Provider Demographics
NPI:1477723591
Name:ORAL SURGERY CENTER OF BISMARCK, PC
Entity Type:Organization
Organization Name:ORAL SURGERY CENTER OF BISMARCK, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MANSUREH
Authorized Official - Middle Name:S
Authorized Official - Last Name:IRAVANI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:701-221-2719
Mailing Address - Street 1:3117 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0664
Mailing Address - Country:US
Mailing Address - Phone:701-221-2719
Mailing Address - Fax:701-221-2819
Practice Address - Street 1:3117 N 14TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0664
Practice Address - Country:US
Practice Address - Phone:701-221-2719
Practice Address - Fax:701-221-2819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND19281223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41342Medicaid
ND24538OtherBCBS
ND949124OtherDENTAL SERVICE CORP
N711603Medicare PIN