Provider Demographics
NPI:1346069135
Name:BLACK HILLS ORTHODONTICS, PROF. L.L.C.
Entity type:Organization
Organization Name:BLACK HILLS ORTHODONTICS, PROF. L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DANA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-717-2722
Mailing Address - Street 1:1165 EGLIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-9634
Mailing Address - Country:US
Mailing Address - Phone:605-646-7930
Mailing Address - Fax:
Practice Address - Street 1:1165 EGLIN ST STE 200
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-9634
Practice Address - Country:US
Practice Address - Phone:605-646-7930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLACK HILLS ORTHODONTICS, PROF. L.L.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty