Provider Demographics
NPI:1306140652
Name:MANKE FAMILY DENTISTRY, PC
Entity type:Organization
Organization Name:MANKE FAMILY DENTISTRY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:MANKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-842-2101
Mailing Address - Street 1:825 E 8TH ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:WINNER
Mailing Address - State:SD
Mailing Address - Zip Code:57580-2634
Mailing Address - Country:US
Mailing Address - Phone:605-842-2101
Mailing Address - Fax:605-842-0493
Practice Address - Street 1:825 E 8TH ST
Practice Address - Street 2:SUITE 203
Practice Address - City:WINNER
Practice Address - State:SD
Practice Address - Zip Code:57580-2634
Practice Address - Country:US
Practice Address - Phone:605-842-2101
Practice Address - Fax:605-842-0493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-30
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM989122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7805410Medicaid