Provider Demographics
NPI:1205393394
Name:BLACK HILLS ORTHODONTICS, PROF. L.L.C.
Entity Type:Organization
Organization Name:BLACK HILLS ORTHODONTICS, PROF. L.L.C.
Other - Org Name:RAPID CITY ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-717-2722
Mailing Address - Street 1:5150 5TH ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-6023
Mailing Address - Country:US
Mailing Address - Phone:605-343-4975
Mailing Address - Fax:
Practice Address - Street 1:5150 5TH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-6023
Practice Address - Country:US
Practice Address - Phone:605-343-4975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLACK HILLS ORTHODONTICS, PROF. L.L.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-25
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental