Provider Demographics
NPI:1508403957
Name:BLACK HILLS MODERN ENDODONTICS
Entity Type:Organization
Organization Name:BLACK HILLS MODERN ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:P
Authorized Official - Last Name:WILBUR
Authorized Official - Suffix:
Authorized Official - Credentials:MDM
Authorized Official - Phone:605-791-5900
Mailing Address - Street 1:655 OMAHA ST STE 400
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-2744
Mailing Address - Country:US
Mailing Address - Phone:605-791-5900
Mailing Address - Fax:
Practice Address - Street 1:655 OMAHA ST STE 400
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-2744
Practice Address - Country:US
Practice Address - Phone:605-791-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental