Healthcare Provider Details

I. General information

NPI: 1457843591
Provider Name (Legal Business Name): DELL RAPIDS DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W 4TH ST
DELL RAPIDS SD
57022-1508
US

IV. Provider business mailing address

10955 ANGLER TRL
GREY EAGLE MN
56336-4766
US

V. Phone/Fax

Practice location:
  • Phone: 605-428-5471
  • Fax:
Mailing address:
  • Phone: 320-247-0953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MATTHEW P FORD
Title or Position: OWNER
Credential: DMD
Phone: 320-234-7095