Healthcare Provider Details

I. General information

NPI: 1740966969
Provider Name (Legal Business Name): CORNELIA ALICE SALLAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 W 41ST ST
SIOUX FALLS SD
57105-6119
US

IV. Provider business mailing address

2116 E ELIZABETH DR
SIOUX FALLS SD
57103-4623
US

V. Phone/Fax

Practice location:
  • Phone: 605-679-7227
  • Fax:
Mailing address:
  • Phone: 615-738-7631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD1450
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: