Provider Demographics
NPI:1932418480
Name:GREGG VAN BEEK DDS PC
Entity Type:Organization
Organization Name:GREGG VAN BEEK DDS PC
Other - Org Name:NORTHEASTERN DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN BEEK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-226-3939
Mailing Address - Street 1:PO BOX 534
Mailing Address - Street 2:
Mailing Address - City:FAULKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57438-0534
Mailing Address - Country:US
Mailing Address - Phone:605-598-4452
Mailing Address - Fax:605-598-4280
Practice Address - Street 1:102 8TH AVE S
Practice Address - Street 2:
Practice Address - City:FAULKTON
Practice Address - State:SD
Practice Address - Zip Code:57438-2115
Practice Address - Country:US
Practice Address - Phone:605-598-4452
Practice Address - Fax:605-598-4280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-01
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM6641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7805395Medicaid