Healthcare Provider Details

I. General information

NPI: 1346069135
Provider Name (Legal Business Name): BLACK HILLS ORTHODONTICS, PROF. L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 EGLIN ST STE 200
RAPID CITY SD
57701-9634
US

IV. Provider business mailing address

1165 EGLIN ST STE 200
RAPID CITY SD
57701-9634
US

V. Phone/Fax

Practice location:
  • Phone: 605-646-7930
  • Fax:
Mailing address:
  • Phone: 605-646-7930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
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: JESSE MICHAEL DANA
Title or Position: VICE PRESIDENT/ORTHODONTIST
Credential: D.D.S.
Phone: 605-717-2722