MEDICARE: CALE SLACK DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	M874	SD

General Provider Information

NPI Number	:	1194820878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CALE SLACK DDS

Provider Business Mailing Address
First Line	:	2425 W 57TH ST
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57108-5026
Country	:	US
Telephone Number	:	605-339-2040
Fax Number	:	605-339-4441

Provider Business Practice Location Address
First Line	:	2425 W 57TH ST
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57108-5026
Country	:	US
Telephone Number	:	605-339-2040
Fax Number	:	605-339-4441

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	07/08/2007

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