Basic Information
| Provider Information | |||||||||
| NPI: | 1073287678 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAKOTA DERMATOLOGY AT SPIRIT LAKE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4950 S. MINNESOTA AVE | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571082864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053309619 | ||||||||
| FaxNumber: | 6053309503 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 23RD ST STE C | ||||||||
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| City: | SPIRIT LAKE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 513601158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053309619 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2021 | ||||||||
| LastUpdateDate: | 09/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | MCGRANN | ||||||||
| AuthorizedOfficialFirstName: | JAMESON | ||||||||
| AuthorizedOfficialMiddleName: | COLIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6053309619 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DAKOTA DERMATOLOGY, LTD | ||||||||
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| NPICertificationDate: | 09/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.