Healthcare Provider Details

I. General information

NPI: 1962306761
Provider Name (Legal Business Name): CUSTOM ENDODONTICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 18TH AVE SE STE 202
MINOT ND
58701-6732
US

IV. Provider business mailing address

601 18TH AVE SE STE 202
MINOT ND
58701-6732
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MICHAELA MUNIZ
Title or Position: VP, PAYOR RELATIONS
Credential:
Phone: 469-324-3242