Provider Demographics
NPI:1427428614
Name:WISEMAN & TIDSTROM DENTAL MANAGEMENT, LLC
Entity type:Organization
Organization Name:WISEMAN & TIDSTROM DENTAL MANAGEMENT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:
Authorized Official - Last Name:WISEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-692-9555
Mailing Address - Street 1:420 FRONT STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006
Mailing Address - Country:US
Mailing Address - Phone:605-692-9555
Mailing Address - Fax:605-692-0967
Practice Address - Street 1:420 FRONT STREET
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006
Practice Address - Country:US
Practice Address - Phone:605-692-9555
Practice Address - Fax:605-692-0967
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WISEMAN & TIDSTROM DENTAL MANAGEMENT, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-30
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD0624122300000X
122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty