Healthcare Provider Details

I. General information

NPI: 1932467875
Provider Name (Legal Business Name): DAMON JAMES THIELEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2012
Last Update Date: 05/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3813 S KIWANIS CIR
SIOUX FALLS SD
57105-4266
US

IV. Provider business mailing address

3813 S KIWANIS CIR
SIOUX FALLS SD
57105-4266
US

V. Phone/Fax

Practice location:
  • Phone: 605-280-2337
  • Fax:
Mailing address:
  • Phone: 605-280-2337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6864-15
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD0982
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: