Provider Demographics
NPI:1699428227
Name:BLACK HILLS IMPLANT AND FAMILY DENTAL LLC
Entity type:Organization
Organization Name:BLACK HILLS IMPLANT AND FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HETTINGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-608-0635
Mailing Address - Street 1:3917 MINNEKAHTA DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-3259
Mailing Address - Country:US
Mailing Address - Phone:605-608-0635
Mailing Address - Fax:
Practice Address - Street 1:1300 JUNCTION AVE
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:SD
Practice Address - Zip Code:57785-1938
Practice Address - Country:US
Practice Address - Phone:605-608-0635
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental