Healthcare Provider Details

I. General information

NPI: 1346424348
Provider Name (Legal Business Name): RONALD G MANN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 PHILIP AVE.
PHILIP SD
57567-1003
US

IV. Provider business mailing address

P. O. BOX 1003 104 PHILIP AVE.
PHILIP SD
57567-1003
US

V. Phone/Fax

Practice location:
  • Phone: 605-859-2491
  • Fax:
Mailing address:
  • Phone: 605-859-2491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberM-648
License Number StateSD

VII. Legacy identifiers

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

# 1
Identifier780-4610
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: