=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649200577
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRYAN GARRY DINGSOR DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2006
-----------------------------------------------------
Last Update Date | 11/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2320 9TH AVE SE
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57201-7112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-882-2304
-----------------------------------------------------
Fax | 605-882-0626
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2320 9TH AVE SE
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57201-7112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-882-2304
-----------------------------------------------------
Fax | 605-882-0626
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1021
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------