Provider Demographics
NPI:1154801090
Name:LISBON DENTISTRY PC
Entity type:Organization
Organization Name:LISBON DENTISTRY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LOURENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-683-7695
Mailing Address - Street 1:PO BOX 1078
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ND
Mailing Address - Zip Code:58054-1078
Mailing Address - Country:US
Mailing Address - Phone:701-683-7695
Mailing Address - Fax:
Practice Address - Street 1:420 MAIN ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054-4142
Practice Address - Country:US
Practice Address - Phone:701-683-7695
Practice Address - Fax:701-683-7698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND19481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty