Healthcare Provider Details

I. General information

NPI: 1023660719
Provider Name (Legal Business Name): DAKOTA DENTAL 4 KIDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5509 BENDT DR STE 302
RAPID CITY SD
57702-9460
US

IV. Provider business mailing address

5509 BENDT DR STE 302
RAPID CITY SD
57702-9460
US

V. Phone/Fax

Practice location:
  • Phone: 605-342-5995
  • Fax:
Mailing address:
  • Phone: 605-342-5995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHRIS TEESLINK
Title or Position: OFFICE MANAGER
Credential:
Phone: 605-342-5995