MEDICARE: RUSHMORE DENTAL PRODUCTS, INC.

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	332B00000X	Durable Medical Equipment & Medical Supplies		SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508801291
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSHMORE DENTAL PRODUCTS, INC.

Provider Business Mailing Address
First Line	:	712 JACKSON BLVD
Second Line	:	SUITE #2
City	:	RAPID CITY
State	:	SD
Zip	:	57702-2554
Country	:	US
Telephone Number	:	605-341-4669
Fax Number	:	605-341-3413

Provider Business Practice Location Address
First Line	:	712 JACKSON BLVD
Second Line	:	SUITE #2
City	:	RAPID CITY
State	:	SD
Zip	:	57702-2554
Country	:	US
Telephone Number	:	605-341-4669
Fax Number	:	605-341-3413

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	MS. PEGGY LEE COYNE
Credential	:	RN, MN
Telephone Number	:	605-341-4669

Provider Enumeration Date	:	06/18/2006
Last Update Date	:	05/26/2010

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