Provider Demographics
NPI:1265925036
Name:PERETS, VITALY (DDS)
Entity type:Individual
Prefix:DR
First Name:VITALY
Middle Name:
Last Name:PERETS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 S STRABANE CIR
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-4512
Mailing Address - Country:US
Mailing Address - Phone:817-807-7073
Mailing Address - Fax:
Practice Address - Street 1:4603 W HOMEFIELD DR
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-3511
Practice Address - Country:US
Practice Address - Phone:605-275-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD1194122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDD1194OtherDENTIST LICENSE NUMBER