MEDICARE: SIOUX FALLS DENTAL IMPLANT CENTER, LLC

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

General Provider Information

NPI Number	:	1508113325
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIOUX FALLS DENTAL IMPLANT CENTER, LLC

Provider Business Mailing Address
First Line	:	330 E STUMER RD
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-6406
Country	:	US
Telephone Number	:	605-716-5622
Fax Number	:	605-348-1626

Provider Business Practice Location Address
First Line	:	3409 W 47TH ST STE 103
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57106-6339
Country	:	US
Telephone Number	:	605-275-2009
Fax Number	:	605-274-2179

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	CHRISTINA MOODY
Credential	:
Telephone Number	:	605-716-5622

Provider Enumeration Date	:	08/10/2012
Last Update Date	:	08/10/2012

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