1376918474 NPI number — DR. BENJAMIN ISAIAH FRIBERG DDS

Table of content: DR. BENJAMIN ISAIAH FRIBERG DDS (NPI 1376918474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376918474 NPI number — DR. BENJAMIN ISAIAH FRIBERG DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRIBERG
Provider First Name:
BENJAMIN
Provider Middle Name:
ISAIAH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376918474
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 860036
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55486-0036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-371-9490
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2029 OLDE REGENT WAY
Provider Second Line Business Practice Location Address:
#150
Provider Business Practice Location Address City Name:
LELAND
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28451-4195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-371-9490
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/01/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D10359 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: 10315 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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