Healthcare Provider Details

I. General information

NPI: 1538889738
Provider Name (Legal Business Name): BLACK HILLS PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2022
Last Update Date: 08/30/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 SHERIDAN LAKE RD
RAPID CITY SD
57702-2407
US

IV. Provider business mailing address

700 SHERIDAN LAKE RD
RAPID CITY SD
57702-2407
US

V. Phone/Fax

Practice location:
  • Phone: 605-341-3068
  • Fax: 605-341-5757
Mailing address:
  • Phone: 605-341-3068
  • Fax: 605-341-5757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
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: PAMM TOROK-HOBEN
Title or Position: CEO
Credential:
Phone: 605-341-3068