Provider Demographics
NPI:1083837199
Name:SODERSTROM IMPLANT DENTISTRY, PC
Entity Type:Organization
Organization Name:SODERSTROM IMPLANT DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SODERSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-388-0930
Mailing Address - Street 1:907 JACKSON BLVD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-2541
Mailing Address - Country:US
Mailing Address - Phone:605-388-0930
Mailing Address - Fax:605-388-0929
Practice Address - Street 1:907 JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-2541
Practice Address - Country:US
Practice Address - Phone:605-388-0930
Practice Address - Fax:605-388-0929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM5371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty