Healthcare Provider Details

I. General information

NPI: 1215909692
Provider Name (Legal Business Name): RANDY LEE KNUTZEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 YORKSHIRE DR
BROOKINGS SD
57006
US

IV. Provider business mailing address

2311 YORKSHIRE DR
BROOKINGS SD
57006
US

V. Phone/Fax

Practice location:
  • Phone: 605-692-9463
  • Fax:
Mailing address:
  • Phone: 605-692-9463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD8104
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberM391
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: