Provider Demographics
NPI:1134330665
Name:DENTAL CLINIC PARTNERSHIP LLC
Entity Type:Organization
Organization Name:DENTAL CLINIC PARTNERSHIP LLC
Other - Org Name:THE DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:A
Authorized Official - Last Name:DETERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-729-2671
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:621 2ND STREET
Mailing Address - City:BRIDGEWATER
Mailing Address - State:SD
Mailing Address - Zip Code:57319
Mailing Address - Country:US
Mailing Address - Phone:605-729-2671
Mailing Address - Fax:605-729-2671
Practice Address - Street 1:621 2ND STREET
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:SD
Practice Address - Zip Code:57319
Practice Address - Country:US
Practice Address - Phone:605-729-2671
Practice Address - Fax:605-729-2671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7800550Medicaid
SD7801500Medicaid