Provider Demographics
NPI:1851422596
Name:CHEYENNE RIVER DENTAL CLINIC
Entity Type:Organization
Organization Name:CHEYENNE RIVER DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRST DENTAL ADMINISTRATIVE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-964-0736
Mailing Address - Street 1:PO BOX 590
Mailing Address - Street 2:
Mailing Address - City:EAGLE BUTTE
Mailing Address - State:SD
Mailing Address - Zip Code:57625-0590
Mailing Address - Country:US
Mailing Address - Phone:605-964-0736
Mailing Address - Fax:605-964-7800
Practice Address - Street 1:24276 166TH ST
Practice Address - Street 2:
Practice Address - City:EAGLE BUTTE
Practice Address - State:SD
Practice Address - Zip Code:57625-8141
Practice Address - Country:US
Practice Address - Phone:605-964-0736
Practice Address - Fax:605-964-7800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2022-08-05
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-07-18
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5540240Medicaid