Provider Demographics
NPI:1326127572
Name:MCCLELLAN-SWANSON DENTAL CLINC, INC.
Entity Type:Organization
Organization Name:MCCLELLAN-SWANSON DENTAL CLINC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER-SHAREHOLDER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:HERBERT
Authorized Official - Last Name:MCCLELLAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:1605-845-7222
Mailing Address - Street 1:509 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOBRIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57601-2130
Mailing Address - Country:US
Mailing Address - Phone:605-845-7222
Mailing Address - Fax:605-845-5532
Practice Address - Street 1:509 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOBRIDGE
Practice Address - State:SD
Practice Address - Zip Code:57601-2130
Practice Address - Country:US
Practice Address - Phone:605-845-7222
Practice Address - Fax:605-845-5532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM7111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7805820Medicaid