Healthcare Provider Details

I. General information

NPI: 1013139393
Provider Name (Legal Business Name): MICHAEL D. HOMER D.M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 S KIWANIS AVE SUITE 100
SIOUX FALLS SD
57105-8119
US

IV. Provider business mailing address

3500 S KIWANIS AVE SUITE 100
SIOUX FALLS SD
57105-8119
US

V. Phone/Fax

Practice location:
  • Phone: 605-336-3446
  • Fax: 605-373-9269
Mailing address:
  • Phone: 605-336-3446
  • Fax: 605-373-9269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD0509
License Number StateSD

VIII. Authorized Official

Name: DR. MICHAEL D. HOMER
Title or Position: PRESIDENT AND CEO
Credential: D.M.D.
Phone: 605-336-3446