Provider Demographics
NPI:1154575199
Name:RANDOLPH R. PITZER DDS PC
Entity type:Organization
Organization Name:RANDOLPH R. PITZER DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRES
Authorized Official - Prefix:
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:PITZER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-774-0259
Mailing Address - Street 1:2224 1ST AVE W
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-6286
Mailing Address - Country:US
Mailing Address - Phone:701-774-0259
Mailing Address - Fax:701-774-0250
Practice Address - Street 1:2224 1ST AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-6286
Practice Address - Country:US
Practice Address - Phone:701-774-0259
Practice Address - Fax:701-774-0250
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RANDOLPH R. PITZER DDS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1628122300000X
ND2010122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND40031Medicaid