Provider Demographics
NPI:1396482295
Name:SANTISTEBAN, RENZO (DMD)
Entity type:Individual
Prefix:
First Name:RENZO
Middle Name:
Last Name:SANTISTEBAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:FAISON
Mailing Address - State:NC
Mailing Address - Zip Code:28341-0187
Mailing Address - Country:US
Mailing Address - Phone:910-267-2042
Mailing Address - Fax:855-996-9090
Practice Address - Street 1:460 SW CENTER ST
Practice Address - Street 2:
Practice Address - City:FAISON
Practice Address - State:NC
Practice Address - Zip Code:28341-8820
Practice Address - Country:US
Practice Address - Phone:910-267-0951
Practice Address - Fax:910-718-9334
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-13
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC129961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program