Provider Demographics
NPI:1518776012
Name:ABRAHAM, RENJITH
Entity type:Individual
Prefix:
First Name:RENJITH
Middle Name:
Last Name:ABRAHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 5TH STREET
Mailing Address - Street 2:
Mailing Address - City:WEYBURN
Mailing Address - State:SASKATCHEWAN
Mailing Address - Zip Code:S4H 0Z7
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3451 S BROADWAY
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-7419
Practice Address - Country:US
Practice Address - Phone:701-858-0552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-31
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ND25511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program