Healthcare Provider Details

I. General information

NPI: 1578313201
Provider Name (Legal Business Name): KAIBAB PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 S 2ND ST
BISMARCK ND
58504-5718
US

IV. Provider business mailing address

714 S 2ND ST
BISMARCK ND
58504-5718
US

V. Phone/Fax

Practice location:
  • Phone: 701-258-3308
  • Fax: 701-751-0349
Mailing address:
  • Phone: 701-258-3308
  • Fax: 701-751-0349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
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: BRIELLE RENZ
Title or Position: OWNER
Credential: DMD
Phone: 701-258-3308