Provider Demographics
NPI:1376522714
Name:RIVER RIDGE ORAL & MAXILLOFACIAL SURGICAL CENTER
Entity Type:Organization
Organization Name:RIVER RIDGE ORAL & MAXILLOFACIAL SURGICAL CENTER
Other - Org Name:RIVER RIDGE ORAL & MAXILLOFACIAL SURGICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-331-5059
Mailing Address - Street 1:1700 S SOUTHEASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-3227
Mailing Address - Country:US
Mailing Address - Phone:605-331-5059
Mailing Address - Fax:605-275-6725
Practice Address - Street 1:1700 S SOUTHEASTERN AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-3227
Practice Address - Country:US
Practice Address - Phone:605-331-5059
Practice Address - Fax:605-275-6725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDNO #1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD104737OtherHEALTH PARTNERSPRACTICE #
SDS100072Medicare PIN