=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053606053
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOUSKA DENTAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2011
-----------------------------------------------------
Last Update Date | 06/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1302 E MAIN ST
-----------------------------------------------------
City | VERMILLION
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57069-2813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-624-3031
-----------------------------------------------------
Fax | 605-624-8084
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1302 E MAIN ST
-----------------------------------------------------
City | VERMILLION
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57069-2813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-624-3031
-----------------------------------------------------
Fax | 605-624-8084
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. RANDY HOUSKA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 605-624-3031
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | M724
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------