Provider Demographics
NPI:1467763995
Name:SHAWD NEIGHBORHOOD DENTAL CLINIC BERESFORD P.C.
Entity Type:Organization
Organization Name:SHAWD NEIGHBORHOOD DENTAL CLINIC BERESFORD P.C.
Other - Org Name:NEIGHBORHOOD DENTAL BERESFORD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HR MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:D
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-731-9599
Mailing Address - Street 1:116 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BERESFORD
Mailing Address - State:SD
Mailing Address - Zip Code:57004-1819
Mailing Address - Country:US
Mailing Address - Phone:605-763-5035
Mailing Address - Fax:605-763-8036
Practice Address - Street 1:116 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BERESFORD
Practice Address - State:SD
Practice Address - Zip Code:57004-1819
Practice Address - Country:US
Practice Address - Phone:605-763-5035
Practice Address - Fax:605-763-8036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD09381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty