Provider Demographics
NPI:1790757011
Name:SIOUXLAND ORAL SURGERY
Entity Type:Organization
Organization Name:SIOUXLAND ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:KRISTIN
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-335-1080
Mailing Address - Street 1:6401 S MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2504
Mailing Address - Country:US
Mailing Address - Phone:605-335-1080
Mailing Address - Fax:605-332-4550
Practice Address - Street 1:6401 S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2504
Practice Address - Country:US
Practice Address - Phone:605-335-1080
Practice Address - Fax:605-332-4550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0002235OtherBCBS GROUP NUMBER
SD2235Medicare ID - Type UnspecifiedGROUP NUMBER