Healthcare Provider Details

I. General information

NPI: 1558434712
Provider Name (Legal Business Name): DAKOTA EAR NOSE & THROAT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 4TH ST SE STE 401
HURON SD
57350
US

IV. Provider business mailing address

172 4TH ST SE STE 401
HURON SD
57350
US

V. Phone/Fax

Practice location:
  • Phone: 605-353-6575
  • Fax: 605-353-6576
Mailing address:
  • Phone: 605-353-6575
  • Fax: 605-353-6576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number48503020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number8429
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number5227
License Number StateSD

VIII. Authorized Official

Name: DR. MOHAMMAD R SHAKER
Title or Position: PRESIDENT DAKOTA ENT CLINIC PC
Credential: MD
Phone: 605-353-6575