Healthcare Provider Details

I. General information

NPI: 1023059771
Provider Name (Legal Business Name): JAMES THEODORE PODREBARAC DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 RAILWAY AV
BISMARCK ND
58501
US

IV. Provider business mailing address

1258 EAGLE CREST LOOP
BISMARCK ND
58503-8849
US

V. Phone/Fax

Practice location:
  • Phone: 701-328-6118
  • Fax: 701-328-6391
Mailing address:
  • Phone: 701-258-1144
  • Fax: 701-328-6391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1973
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: