Healthcare Provider Details

I. General information

NPI: 1518776012
Provider Name (Legal Business Name): RENJITH ABRAHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2024
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3451 S BROADWAY
MINOT ND
58701-7419
US

IV. Provider business mailing address

449 5TH STREET
WEYBURN SASKATCHEWAN
S4H 0Z7
CA

V. Phone/Fax

Practice location:
  • Phone: 701-858-0552
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2551
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: