Provider Demographics
NPI:1912048687
Name:NORTH SIOUX DENTAL CLINIC
Entity Type:Organization
Organization Name:NORTH SIOUX DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:B
Authorized Official - Last Name:CORK
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-232-8802
Mailing Address - Street 1:101 MERRILL AVE.
Mailing Address - Street 2:PO BOX 1010
Mailing Address - City:NORTH SIOUX CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57049
Mailing Address - Country:US
Mailing Address - Phone:605-232-8802
Mailing Address - Fax:605-232-0973
Practice Address - Street 1:101 MERRILL AVE.
Practice Address - Street 2:
Practice Address - City:NORTH SIOUX CITY
Practice Address - State:SD
Practice Address - Zip Code:57049
Practice Address - Country:US
Practice Address - Phone:605-232-8802
Practice Address - Fax:605-232-0973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM8471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0722009Medicaid
IA0989517Medicaid
NE=========13Medicaid
IA0722009Medicaid