MEDICARE: BLACK HILLS ORTHODONTICS, PROF. L.L.C.

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1205393394
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK HILLS ORTHODONTICS, PROF. L.L.C.

Provider Business Mailing Address
First Line	:	5150 5TH ST
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-6023
Country	:	US
Telephone Number	:	605-343-4975
Fax Number	:

Provider Business Practice Location Address
First Line	:	5150 5TH ST
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-6023
Country	:	US
Telephone Number	:	605-343-4975
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JESSE MICHAEL DANA
Credential	:
Telephone Number	:	605-717-2722

Provider Enumeration Date	:	02/25/2019
Last Update Date	:	03/02/2021

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