Provider Demographics
NPI:1508801291
Name:RUSHMORE DENTAL PRODUCTS, INC.
Entity Type:Organization
Organization Name:RUSHMORE DENTAL PRODUCTS, INC.
Other - Org Name:PRESIDENTS SPECIALTY HEALTH CARE SUPPLIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:COYNE
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MN
Authorized Official - Phone:605-341-4669
Mailing Address - Street 1:712 JACKSON BLVD
Mailing Address - Street 2:SUITE #2
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-2554
Mailing Address - Country:US
Mailing Address - Phone:605-341-4669
Mailing Address - Fax:605-341-3413
Practice Address - Street 1:712 JACKSON BLVD
Practice Address - Street 2:SUITE #2
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-2554
Practice Address - Country:US
Practice Address - Phone:605-341-4669
Practice Address - Fax:605-341-3413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9165300Medicaid
SD9165300Medicaid