MEDICARE: DR. VITALY PERETS 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	122300000X	Dentist	D1194	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D1194	OTHER	SD	DENTIST LICENSE NUMBER

General Provider Information

NPI Number	:	1265925036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VITALY PERETS DDS

Provider Business Mailing Address
First Line	:	1812 S STRABANE CIR
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57106-4512
Country	:	US
Telephone Number	:	817-807-7073
Fax Number	:

Provider Business Practice Location Address
First Line	:	4603 W HOMEFIELD DR
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57106-3511
Country	:	US
Telephone Number	:	605-275-2424
Fax Number	:

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

Provider Enumeration Date	:	06/07/2018
Last Update Date	:	06/07/2018

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