Provider Demographics
NPI:1588404339
Name:SD SPECIALTY DENTAL SERVICES, LLC
Entity type:Organization
Organization Name:SD SPECIALTY DENTAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIREC OF CRED AND PR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:
Authorized Official - Last Name:DASCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-638-0303
Mailing Address - Street 1:1610 54TH AVE N STE 205
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209-1442
Mailing Address - Country:US
Mailing Address - Phone:615-678-0759
Mailing Address - Fax:
Practice Address - Street 1:220 RYAN RD
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-1211
Practice Address - Country:US
Practice Address - Phone:605-717-2722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SD SPECIALTY DENTAL SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty