Provider Demographics
NPI:1588865950
Name:SOUTHEASTERN DENTAL CENTER
Entity type:Organization
Organization Name:SOUTHEASTERN DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KOHLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-335-8030
Mailing Address - Street 1:2851 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-3511
Mailing Address - Country:US
Mailing Address - Phone:605-335-8030
Mailing Address - Fax:605-335-0984
Practice Address - Street 1:2851 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-3511
Practice Address - Country:US
Practice Address - Phone:605-335-8030
Practice Address - Fax:605-335-0984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM6051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty