Provider Demographics
NPI:1376352500
Name:IMPACT DENTAL
Entity type:Organization
Organization Name:IMPACT DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-799-2525
Mailing Address - Street 1:108 S MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-6414
Mailing Address - Country:US
Mailing Address - Phone:605-799-2525
Mailing Address - Fax:
Practice Address - Street 1:108 S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-6414
Practice Address - Country:US
Practice Address - Phone:605-799-2525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-02
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental