Provider Demographics
NPI:1538510482
Name:PROUTY BROOKINGS DENTAL, LLC
Entity Type:Organization
Organization Name:PROUTY BROOKINGS DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:KELLY
Authorized Official - Last Name:PROUTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-886-8394
Mailing Address - Street 1:2220 YORKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-2442
Mailing Address - Country:US
Mailing Address - Phone:605-697-6262
Mailing Address - Fax:605-692-1521
Practice Address - Street 1:2220 YORKSHIRE DR
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2442
Practice Address - Country:US
Practice Address - Phone:605-697-6262
Practice Address - Fax:605-692-1521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-22
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM983122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty