Healthcare Provider Details

I. General information

NPI: 1124468590
Provider Name (Legal Business Name): CUSTOM ENDODONTICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2013
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 E MAIN AVE SUITE 100
BISMARCK ND
58501-4418
US

IV. Provider business mailing address

521 E MAIN AVE SUITE 100
BISMARCK ND
58501-4418
US

V. Phone/Fax

Practice location:
  • Phone: 701-255-2523
  • Fax: 701-525-5765
Mailing address:
  • Phone: 701-255-2523
  • Fax: 701-525-5765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. STEVE W OSMOND
Title or Position: DOCTOR/OWNER
Credential: DDS, MSD
Phone: 701-255-2523