Provider Demographics
NPI:1023059771
Name:PODREBARAC, JAMES THEODORE (DDS)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:THEODORE
Last Name:PODREBARAC
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1258 EAGLE CREST LOOP
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-8849
Mailing Address - Country:US
Mailing Address - Phone:701-258-1144
Mailing Address - Fax:701-328-6391
Practice Address - Street 1:3100 RAILWAY AV
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501
Practice Address - Country:US
Practice Address - Phone:701-328-6118
Practice Address - Fax:701-328-6391
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1973122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist