Healthcare Provider Details

I. General information

NPI: 1851422596
Provider Name (Legal Business Name): CHEYENNE RIVER DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date: 07/17/2007
Reactivation Date: 07/18/2007

III. Provider practice location address

24276 166TH ST
EAGLE BUTTE SD
57625-8141
US

IV. Provider business mailing address

PO BOX 590
EAGLE BUTTE SD
57625-0590
US

V. Phone/Fax

Practice location:
  • Phone: 605-964-0736
  • Fax: 605-964-7800
Mailing address:
  • Phone: 605-964-0736
  • Fax: 605-964-7800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MRS. TIFFANY L LARSON
Title or Position: CRST DENTAL ADMINISTRATIVE MANAGER
Credential:
Phone: 605-964-0736