Healthcare Provider Details

I. General information

NPI: 1790757011
Provider Name (Legal Business Name): SIOUXLAND ORAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 04/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 S MINNESOTA AVE
SIOUX FALLS SD
57108-2504
US

IV. Provider business mailing address

6401 S MINNESOTA AVE
SIOUX FALLS SD
57108-2504
US

V. Phone/Fax

Practice location:
  • Phone: 605-335-1080
  • Fax: 605-332-4550
Mailing address:
  • Phone: 605-335-1080
  • Fax: 605-332-4550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MRS. PEGGY KRISTIN ROTH
Title or Position: INSURANCE ADMINISTRATOR
Credential:
Phone: 605-335-1080