Provider Demographics
NPI:1508113325
Name:SIOUX FALLS DENTAL IMPLANT CENTER, LLC
Entity Type:Organization
Organization Name:SIOUX FALLS DENTAL IMPLANT CENTER, LLC
Other - Org Name:THE DENTAL IMPLANT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-716-5622
Mailing Address - Street 1:330 E STUMER RD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-6406
Mailing Address - Country:US
Mailing Address - Phone:605-716-5622
Mailing Address - Fax:605-348-1626
Practice Address - Street 1:3409 W 47TH ST STE 103
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-6339
Practice Address - Country:US
Practice Address - Phone:605-275-2009
Practice Address - Fax:605-274-2179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty