Provider Demographics
NPI:1578169264
Name:INFINITY IMPLANT AND SEDATION DENTISTRY BLACK HILLS LLC
Entity Type:Organization
Organization Name:INFINITY IMPLANT AND SEDATION DENTISTRY BLACK HILLS 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:605-878-0456
Mailing Address - Street 1:4215 BERNIECE ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57703-6410
Mailing Address - Country:US
Mailing Address - Phone:605-343-6691
Mailing Address - Fax:
Practice Address - Street 1:4215 BERNIECE ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57703-6410
Practice Address - Country:US
Practice Address - Phone:605-343-6691
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty