Provider Demographics
NPI:1578926333
Name:PRAIRIE RIDGE ENDODONTICS
Entity Type:Organization
Organization Name:PRAIRIE RIDGE ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:HAWLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-878-0180
Mailing Address - Street 1:600 4TH ST NE SUITE 101
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201
Mailing Address - Country:US
Mailing Address - Phone:605-878-0180
Mailing Address - Fax:605-878-0181
Practice Address - Street 1:600 4TH ST NE SUITE 101
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201
Practice Address - Country:US
Practice Address - Phone:605-878-0180
Practice Address - Fax:605-878-0181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-30
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD05151223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1891775904OtherTYPE 1 NPI