Healthcare Provider Details

I. General information

NPI: 1053385468
Provider Name (Legal Business Name): BRYAN M VIBETO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 07/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 ELK DR STE 2
MINOT ND
58701-0001
US

IV. Provider business mailing address

2615 ELK DR STE 2
MINOT ND
58701-1200
US

V. Phone/Fax

Practice location:
  • Phone: 701-839-6010
  • Fax:
Mailing address:
  • Phone: 701-839-6010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number11516
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1979
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: