Provider Demographics
NPI:1376790626
Name:USD DENTAL CLINIC
Entity Type:Organization
Organization Name:USD DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT CHAIRPERSON
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNICK
Authorized Official - Suffix:
Authorized Official - Credentials:PROFESSOR
Authorized Official - Phone:605-677-5580
Mailing Address - Street 1:521 N MAIN AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-5948
Mailing Address - Country:US
Mailing Address - Phone:605-367-8046
Mailing Address - Fax:605-677-8048
Practice Address - Street 1:521 N MAIN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-5948
Practice Address - Country:US
Practice Address - Phone:605-367-8046
Practice Address - Fax:605-677-8048
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:USD DENTAL HYGIENE OF VERMILLION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-19
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD0802261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental