Basic Information
| Provider Information | |||||||||
| NPI: | 1396717229 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRESTON | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 TOWER ROAD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DAKOTA DUNES | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052174310 | ||||||||
| FaxNumber: | 6052172915 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 TOWER ROAD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DAKOTA DUNES | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052174310 | ||||||||
| FaxNumber: | 6052172915 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2006 | ||||||||
| LastUpdateDate: | 10/25/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 02660 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 3502 | SD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 0004023 | 01 | SD | BLUE CROSS BLUE SHIELD | OTHER | 42140591500 | 05 | NE | MEDICAID | 12129 | 01 | IA | BLUE CROSS BLUE SHIELD | OTHER | 1074542 | 05 | IA | MEDICAID | 7797132 | 05 | SD | MEDICAID |