Healthcare Provider Details

I. General information

NPI: 1265598742
Provider Name (Legal Business Name): BROOKINGS DENTAL CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 DERDALL DR
BROOKINGS SD
57006-2851
US

IV. Provider business mailing address

2215 DERDALL DR
BROOKINGS SD
57006-2851
US

V. Phone/Fax

Practice location:
  • Phone: 605-692-1222
  • Fax:
Mailing address:
  • Phone: 605-692-1222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateSD

VIII. Authorized Official

Name: DR. GEOFFREY B JOHNSON
Title or Position: OFFICER
Credential: DDS
Phone: 605-692-1222