Provider Demographics
NPI:1568035160
Name:PRODOEHL, DEVYN JEAN
Entity Type:Individual
Prefix:
First Name:DEVYN
Middle Name:JEAN
Last Name:PRODOEHL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3026 SUNNYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-4280
Mailing Address - Country:US
Mailing Address - Phone:605-695-7217
Mailing Address - Fax:
Practice Address - Street 1:401 PRAIRIE AVE SW
Practice Address - Street 2:
Practice Address - City:DE SMET
Practice Address - State:SD
Practice Address - Zip Code:57231-2333
Practice Address - Country:US
Practice Address - Phone:605-854-3444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD13211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice