Provider Demographics
NPI:1063486926
Name:BLACK HILLS ORAL & MAXILLOFACIAL SURGERY PC
Entity Type:Organization
Organization Name:BLACK HILLS ORAL & MAXILLOFACIAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:CAVE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:605-348-6818
Mailing Address - Street 1:PO BOX 5690
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-5690
Mailing Address - Country:US
Mailing Address - Phone:605-348-6818
Mailing Address - Fax:605-348-4690
Practice Address - Street 1:3415 5TH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7365
Practice Address - Country:US
Practice Address - Phone:605-348-6818
Practice Address - Fax:605-348-4690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM3671223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD8000140Medicaid
SD8000050Medicaid
SDT66423Medicare UPIN
SD57152Medicare ID - Type Unspecified
SDU35043Medicare UPIN
SD8000140Medicaid