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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1659541225
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK HILLS ORTHODONTICS, PROF. L.L.C.

Provider Business Mailing Address
First Line	:	2620 JACKSON BLVD STE A
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-3478
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2620 JACKSON BLVD STE A
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-3478
Country	:	US
Telephone Number	:	605-343-1500
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT/ORTHODONTIST
Name	:	JESSE DANA
Credential	:	D.D.S.
Telephone Number	:	605-343-1500

Provider Enumeration Date	:	03/10/2008
Last Update Date	:	03/02/2021

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