Provider Demographics
NPI:1073287678
Name:DAKOTA DERMATOLOGY AT SPIRIT LAKE PC
Entity Type:Organization
Organization Name:DAKOTA DERMATOLOGY AT SPIRIT LAKE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMESON
Authorized Official - Middle Name:COLIN
Authorized Official - Last Name:MCGRANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-330-9619
Mailing Address - Street 1:4950 S. MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2864
Mailing Address - Country:US
Mailing Address - Phone:605-330-9619
Mailing Address - Fax:605-330-9503
Practice Address - Street 1:2700 23RD ST STE C
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360-1158
Practice Address - Country:US
Practice Address - Phone:605-330-9619
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAKOTA DERMATOLOGY, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-06
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty