Healthcare Provider Details

I. General information

NPI: 1780741413
Provider Name (Legal Business Name): BENJAMIN L. GATES, DDS, PROF, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 06/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 MAIN AVE S SUITE 2
BROOKINGS SD
57006-3118
US

IV. Provider business mailing address

305 MAIN AVE S SUITE 2
BROOKINGS SD
57006-3118
US

V. Phone/Fax

Practice location:
  • Phone: 605-692-2820
  • Fax: 605-692-9116
Mailing address:
  • Phone: 605-692-2820
  • Fax: 605-692-9116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberM641
License Number StateSD

VIII. Authorized Official

Name: DR. BENJAMIN L GATES
Title or Position: DOCTOR
Credential:
Phone: 605-692-2820