Healthcare Provider Details

I. General information

NPI: 1609896349
Provider Name (Legal Business Name): STEPHEN DALE GULLINGS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E 4TH AVE
MITCHELL SD
57301-2605
US

IV. Provider business mailing address

205 E. 4TH AVE.
MITCHELL SD
57301-2605
US

V. Phone/Fax

Practice location:
  • Phone: 605-996-2411
  • Fax: 605-996-2411
Mailing address:
  • Phone: 605-996-2411
  • Fax: 605-996-2411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberM497
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier7803132
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: