Healthcare Provider Details

I. General information

NPI: 1902512163
Provider Name (Legal Business Name): PREMIER ENDODONTICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 QUINCY ST STE 2
RAPID CITY SD
57701-3674
US

IV. Provider business mailing address

13170 BRIDGE LN
RAPID CITY SD
57702-8523
US

V. Phone/Fax

Practice location:
  • Phone: 605-868-6422
  • Fax:
Mailing address:
  • Phone: 605-868-6422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. STEVEN FREDERICK WISWALL
Title or Position: PRESIDENT
Credential: DMD, MS
Phone: 605-868-6422