Provider Demographics
NPI:1114796422
Name:ISD NATIONAL CLINIC LLC
Entity Type:Organization
Organization Name:ISD NATIONAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PROUTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-275-2009
Mailing Address - Street 1:856 POMPESKA DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-5463
Mailing Address - Country:US
Mailing Address - Phone:605-275-2009
Mailing Address - Fax:605-884-9133
Practice Address - Street 1:4320 S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-6747
Practice Address - Country:US
Practice Address - Phone:605-275-2009
Practice Address - Fax:605-884-9133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty