Provider Demographics
NPI:1396836466
Name:ADVANCED FAMILY DENTAL PC
Entity Type:Organization
Organization Name:ADVANCED FAMILY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:W
Authorized Official - Last Name:SEGRIST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-716-7509
Mailing Address - Street 1:1801 MOUNT RUSHMORE RD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-4564
Mailing Address - Country:US
Mailing Address - Phone:605-716-7509
Mailing Address - Fax:605-716-7799
Practice Address - Street 1:1801 MOUNT RUSHMORE RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-4564
Practice Address - Country:US
Practice Address - Phone:605-716-7509
Practice Address - Fax:605-716-7799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM9601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1457452435Medicare UPIN