MEDICARE: IMPLANT & SEDATION DENTISTRY 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		SD

General Provider Information

NPI Number	:	1588025514
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPLANT & SEDATION DENTISTRY LLC

Provider Business Mailing Address
First Line	:	2300 9TH AVE SE
Second Line	:
City	:	WATERTOWN
State	:	SD
Zip	:	57201-7112
Country	:	US
Telephone Number	:	605-275-2009
Fax Number	:	605-886-5209

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	:	605-886-5209

Authorized Official
Title or Position	:	OWNER
Name	:	BRIAN KELLY PROUTY
Credential	:	DDS
Telephone Number	:	605-275-2009

Provider Enumeration Date	:	03/18/2016
Last Update Date	:	03/18/2016

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