Healthcare Provider Details

I. General information

NPI: 1073189866
Provider Name (Legal Business Name): NORTHERN PLAINS ENDODONTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4824 E 57TH ST
SIOUX FALLS SD
57108-8614
US

IV. Provider business mailing address

4824 E 57TH ST
SIOUX FALLS SD
57108-8614
US

V. Phone/Fax

Practice location:
  • Phone: 319-610-5747
  • Fax: 605-961-9093
Mailing address:
  • Phone: 605-961-9092
  • Fax: 605-961-9093

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:

# 1
Identifier14275005056
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name: DR. ZACHARY GOETTSCHE
Title or Position: OWNER DENTIST
Credential: DDS
Phone: 605-961-9092