Provider Demographics
NPI:1588025514
Name:IMPLANT & SEDATION DENTISTRY LLC
Entity type:Organization
Organization Name:IMPLANT & SEDATION DENTISTRY 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:605-275-2009
Mailing Address - Street 1:2300 9TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-7112
Mailing Address - Country:US
Mailing Address - Phone:605-275-2009
Mailing Address - Fax:605-886-5209
Practice Address - Street 1:3409 W 47TH ST STE 103
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-6339
Practice Address - Country:US
Practice Address - Phone:605-275-2009
Practice Address - Fax:605-886-5209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-18
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty