Healthcare Provider Details

I. General information

NPI: 1396482295
Provider Name (Legal Business Name): RENZO SANTISTEBAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2022
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 SW CENTER ST
FAISON NC
28341-8820
US

IV. Provider business mailing address

PO BOX 187
FAISON NC
28341-0187
US

V. Phone/Fax

Practice location:
  • Phone: 910-267-0951
  • Fax: 910-718-9334
Mailing address:
  • Phone: 910-267-2042
  • Fax: 855-996-9090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12996
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: