Healthcare Provider Details

I. General information

NPI: 1376352500
Provider Name (Legal Business Name): IMPACT DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2025
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 S MINNESOTA AVE
SIOUX FALLS SD
57104-6414
US

IV. Provider business mailing address

108 S MINNESOTA AVE
SIOUX FALLS SD
57104-6414
US

V. Phone/Fax

Practice location:
  • Phone: 605-799-2525
  • Fax:
Mailing address:
  • Phone: 605-799-2525
  • 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: DR. ANTHONY OLSON
Title or Position: OWNER
Credential: DDS
Phone: 605-799-2525