Provider Demographics
NPI:1962983205
Name:DAKOTA REGIONAL PERIODONTICS, LLC
Entity type:Organization
Organization Name:DAKOTA REGIONAL PERIODONTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-348-2556
Mailing Address - Street 1:2800 JACKSON BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-3477
Mailing Address - Country:US
Mailing Address - Phone:605-348-2556
Mailing Address - Fax:
Practice Address - Street 1:2800 JACKSON BLVD STE 6
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-3477
Practice Address - Country:US
Practice Address - Phone:605-348-2556
Practice Address - Fax:605-348-1526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty