Provider Demographics
NPI:1124512140
Name:ISHIBASHI, KERI (DMD)
Entity type:Individual
Prefix:
First Name:KERI
Middle Name:
Last Name:ISHIBASHI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BIGFORK
Mailing Address - State:MN
Mailing Address - Zip Code:56628-2001
Mailing Address - Country:US
Mailing Address - Phone:218-743-3600
Mailing Address - Fax:
Practice Address - Street 1:303 MAIN ST
Practice Address - Street 2:
Practice Address - City:BIGFORK
Practice Address - State:MN
Practice Address - Zip Code:56628-2001
Practice Address - Country:US
Practice Address - Phone:218-743-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-22
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND140531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice