Healthcare Provider Details

I. General information

NPI: 1679042519
Provider Name (Legal Business Name): PRAIRIE ROSE FAMILY DENTISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2018
Last Update Date: 11/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 COLLEGE DR. SUITE 110
BISMARK ND
58501
US

IV. Provider business mailing address

121 E. FRONT AVE.
BISMARK ND
58504
US

V. Phone/Fax

Practice location:
  • Phone: 701-258-8100
  • Fax:
Mailing address:
  • Phone: 701-223-1194
  • Fax: 701-250-9614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHARD J HIEB
Title or Position: PARTNER
Credential: DDS
Phone: 701-223-1194