Provider Demographics
NPI:1578313201
Name:KAIBAB PC
Entity Type:Organization
Organization Name:KAIBAB PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:RENZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:701-258-3308
Mailing Address - Street 1:714 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-5718
Mailing Address - Country:US
Mailing Address - Phone:701-258-3308
Mailing Address - Fax:701-751-0349
Practice Address - Street 1:714 S 2ND ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5718
Practice Address - Country:US
Practice Address - Phone:701-258-3308
Practice Address - Fax:701-751-0349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment