Healthcare Provider Details

I. General information

NPI: 1043351018
Provider Name (Legal Business Name): DESTINATION DENTAL PROFESSIONALS II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2007
Last Update Date: 08/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 N 5TH ST
CUSTER SD
57730-1528
US

IV. Provider business mailing address

141 N 5TH ST
CUSTER SD
57730-1528
US

V. Phone/Fax

Practice location:
  • Phone: 605-673-2011
  • Fax:
Mailing address:
  • Phone: 605-673-2011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberM-490
License Number StateSD

VIII. Authorized Official

Name: DIANA LATINOW
Title or Position: DENTIST / OWNER
Credential: DDS
Phone: 605-673-2011