Provider Demographics
NPI:1396717229
Name:PRESTON, KEVIN L (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:L
Last Name:PRESTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 TOWER ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DAKOTA DUNES
Mailing Address - State:SD
Mailing Address - Zip Code:57049
Mailing Address - Country:US
Mailing Address - Phone:605-217-4310
Mailing Address - Fax:605-217-2915
Practice Address - Street 1:101 TOWER ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049
Practice Address - Country:US
Practice Address - Phone:605-217-4310
Practice Address - Fax:605-217-2915
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-04
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02660207RG0100X
SD3502207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0004023OtherBLUE CROSS BLUE SHIELD
NE42140591500Medicaid
IA12129OtherBLUE CROSS BLUE SHIELD
IA1074542Medicaid
SD7797132Medicaid
SD0004023OtherBLUE CROSS BLUE SHIELD
NE42140591500Medicaid
IA1074542Medicaid
SD4023Medicare ID - Type Unspecified