Healthcare Provider Details

I. General information

NPI: 1215204029
Provider Name (Legal Business Name): PLATTE DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2011
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E. 7TH ST. STE #5
PLATTE SD
57369-0250
US

IV. Provider business mailing address

PO BOX 250 601 E. 7TH ST. STE #5
PLATTE SD
57369-0250
US

V. Phone/Fax

Practice location:
  • Phone: 605-337-3810
  • Fax: 605-337-2617
Mailing address:
  • Phone: 605-337-3810
  • Fax: 605-337-2617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberM925
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberM683
License Number StateSD

VII. Legacy identifiers

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

# 1
Identifier7805980
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer
# 2
Identifier10025648200
Identifier TypeMEDICAID
Identifier StateNE
Identifier Issuer

VIII. Authorized Official

Name: LANCE R. GRIESE
Title or Position: DDS
Credential: DDS
Phone: 605-337-3810