Provider Demographics
NPI:1659541225
Name:BLACK HILLS ORTHODONTICS, PROF. L.L.C.
Entity Type:Organization
Organization Name:BLACK HILLS ORTHODONTICS, PROF. L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:DANA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-343-1500
Mailing Address - Street 1:2620 JACKSON BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-3478
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2620 JACKSON BLVD STE A
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-3478
Practice Address - Country:US
Practice Address - Phone:605-343-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty