Healthcare Provider Details

I. General information

NPI: 1407662059
Provider Name (Legal Business Name): EMBRACE MADISON DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2024
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 N EGAN AVE
MADISON SD
57042-2909
US

IV. Provider business mailing address

102 N EGAN AVE
MADISON SD
57042-2909
US

V. Phone/Fax

Practice location:
  • Phone: 605-256-4969
  • Fax:
Mailing address:
  • Phone: 605-256-4969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: BRIAN PROUTY
Title or Position: OWNER
Credential: DDS
Phone: 605-884-9341