| Organization Name: | CLEAR LAKE DENTAL LLC |
| NPI Number: | 1629436381 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | BRIAN KELLY PROUTY (OWNER) |
| Mailing Address: | 210 3rd Ave South Clear Lake |
| State: | SD US |
| Postal Code: | 57226 |
| Phone Number: | 6058742230 |
| Fax Number: | 6058742675 |
| NPI Enumeration Date: | 02/09/2016 |
| NPI Last Update Date: | 02/09/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QD0000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Dental |
| Taxonomy Definition: | |