1700259496 NPI number — CHRIS DICKES FAMILY DENTISTRY, PROF. LLC

Table of content: (NPI 1700259496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700259496 NPI number — CHRIS DICKES FAMILY DENTISTRY, PROF. LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHRIS DICKES FAMILY DENTISTRY, PROF. LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700259496
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 W 4TH ST
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
YANKTON
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57078-3700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-660-8409
Provider Business Mailing Address Fax Number:
605-665-4584

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1704 S CLEVELAND AVE
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57103-3903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-660-8409
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/04/2015

Additional Information

Authorized Official

Authorized Official Last Name:
DICKES
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
D
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
605-376-7256

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D0519 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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