MEDICARE: PEDIATRIC DENTISTRY PC

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	1223D0001X	Public Health Dentistry	M991	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	:	1962828285
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC DENTISTRY PC

Provider Business Mailing Address
First Line	:	711 SIOUX POINT RD. STE. 100
Second Line	:
City	:	DAKOTA DUNES
State	:	SD
Zip	:	57049-5099
Country	:	US
Telephone Number	:	605-242-4700
Fax Number	:	605-242-4702

Provider Business Practice Location Address
First Line	:	711 SIOUX POINT RD. STE. 100
Second Line	:
City	:	DAKOTA DUNES
State	:	SD
Zip	:	57049-5099
Country	:	US
Telephone Number	:	605-242-4700
Fax Number	:	605-242-4702

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	JEANNE S. HANSEN
Credential	:
Telephone Number	:	605-242-4700

Provider Enumeration Date	:	03/11/2014
Last Update Date	:	11/18/2016

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Directions to “PEDIATRIC DENTISTRY PC ” Practice Location

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