Healthcare Provider Details

I. General information

NPI: 1104040872
Provider Name (Legal Business Name): JESSE MICHAEL DANA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 N MAIN ST
SPEARFISH SD
57783-1503
US

IV. Provider business mailing address

1306 N MAIN ST
SPEARFISH SD
57783-1503
US

V. Phone/Fax

Practice location:
  • Phone: 605-717-2722
  • Fax: 605-722-7645
Mailing address:
  • Phone: 605-717-2722
  • Fax: 605-722-7645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberM961
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: