Provider Demographics
NPI:1679042519
Name:PRAIRIE ROSE FAMILY DENTISTS
Entity Type:Organization
Organization Name:PRAIRIE ROSE FAMILY DENTISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:HIEB
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:BISMARK
Mailing Address - State:ND
Mailing Address - Zip Code:58504
Mailing Address - Country:US
Mailing Address - Phone:701-223-1194
Mailing Address - Fax:701-250-9614
Practice Address - Street 1:1110 COLLEGE DR.
Practice Address - Street 2:SUITE 110
Practice Address - City:BISMARK
Practice Address - State:ND
Practice Address - Zip Code:58501
Practice Address - Country:US
Practice Address - Phone:701-258-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRAIRIE ROSE FAMILY DENTISTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-21
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty