Provider Demographics
NPI:1194867499
Name:BLACK HILLS PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:BLACK HILLS PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMM
Authorized Official - Middle Name:
Authorized Official - Last Name:TOROK-HOBEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-341-3068
Mailing Address - Street 1:700 SHERIDAN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-2407
Mailing Address - Country:US
Mailing Address - Phone:605-341-3068
Mailing Address - Fax:605-341-5757
Practice Address - Street 1:700 SHERIDAN LAKE RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-2407
Practice Address - Country:US
Practice Address - Phone:605-341-3068
Practice Address - Fax:605-341-5757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100249748-00Medicaid
WY118314100Medicaid
SD7805000Medicaid