Provider Demographics
NPI:1629436381
Name:CLEAR LAKE DENTAL LLC
Entity Type:Organization
Organization Name:CLEAR LAKE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
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:605-874-2230
Mailing Address - Street 1:210 3RD AVE SOUTH
Mailing Address - Street 2:
Mailing Address - City:CLEAR LAKE
Mailing Address - State:SD
Mailing Address - Zip Code:57226
Mailing Address - Country:US
Mailing Address - Phone:605-874-2230
Mailing Address - Fax:604-874-2675
Practice Address - Street 1:210 3RD AVE SOUTH
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:SD
Practice Address - Zip Code:57226
Practice Address - Country:US
Practice Address - Phone:605-874-2230
Practice Address - Fax:605-874-2675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental