Provider Demographics
NPI:1902226004
Name:REARDON DENTAL CLINIC PROF LLC
Entity Type:Organization
Organization Name:REARDON DENTAL CLINIC PROF LLC
Other - Org Name:YANKTON DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:REARDON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-668-2273
Mailing Address - Street 1:1100 BROADWAY AVE
Mailing Address - Street 2:PO BOX 573
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-2927
Mailing Address - Country:US
Mailing Address - Phone:605-668-2273
Mailing Address - Fax:605-668-2273
Practice Address - Street 1:1100 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-2927
Practice Address - Country:US
Practice Address - Phone:605-668-2273
Practice Address - Fax:605-668-2273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM8241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty