Provider Demographics
NPI:1962828285
Name:PEDIATRIC DENTISTRY PC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY PC
Other - Org Name:DBA. DUNES DENTAL 4 KIDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:S
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-242-4700
Mailing Address - Street 1:711 SIOUX POINT RD. STE. 100
Mailing Address - Street 2:
Mailing Address - City:DAKOTA DUNES
Mailing Address - State:SD
Mailing Address - Zip Code:57049-5099
Mailing Address - Country:US
Mailing Address - Phone:605-242-4700
Mailing Address - Fax:605-242-4702
Practice Address - Street 1:711 SIOUX POINT RD. STE. 100
Practice Address - Street 2:
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049-5099
Practice Address - Country:US
Practice Address - Phone:605-242-4700
Practice Address - Fax:605-242-4702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-11
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM9911223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0234450Medicaid