Healthcare Provider Details

I. General information

NPI: 1427428614
Provider Name (Legal Business Name): WISEMAN & TIDSTROM DENTAL MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 03/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 FRONT STREET
BROOKINGS SD
57006
US

IV. Provider business mailing address

420 FRONT STREET
BROOKINGS SD
57006
US

V. Phone/Fax

Practice location:
  • Phone: 605-692-9555
  • Fax: 605-692-0967
Mailing address:
  • Phone: 605-692-9555
  • Fax: 605-692-0967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD0624
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: ERIK WISEMAN
Title or Position: DENTIST / OWNER
Credential: D.D.S.
Phone: 605-692-9555