Provider Demographics
NPI:1326136607
Name:SOUTH WESTERN DENTAL
Entity Type:Organization
Organization Name:SOUTH WESTERN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:WEISBECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-339-2200
Mailing Address - Street 1:5201 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-5004
Mailing Address - Country:US
Mailing Address - Phone:605-339-2200
Mailing Address - Fax:605-334-5530
Practice Address - Street 1:5201 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-5004
Practice Address - Country:US
Practice Address - Phone:605-339-2200
Practice Address - Fax:605-334-5530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0937011Medicaid
SD7803400Medicaid
MN926228Medicaid