Provider Demographics
NPI:1487790234
Name:DAWN WATTENHOFER, O.D., P.C.
Entity type:Organization
Organization Name:DAWN WATTENHOFER, O.D., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:WATTENHOFER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:605-343-1200
Mailing Address - Street 1:2200 N MAPLE AVE STE D-252
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7854
Mailing Address - Country:US
Mailing Address - Phone:605-343-1200
Mailing Address - Fax:605-343-9752
Practice Address - Street 1:2200 N MAPLE AVE
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7854
Practice Address - Country:US
Practice Address - Phone:605-343-1200
Practice Address - Fax:605-343-9752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDSD0553152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0006984OtherBCBS
SD9200982Medicaid
SDSD0563OtherLIC.# FOR DEREK ALLMER
SDSD0553OtherLIC.# FOR DAWN WATTENHOFE
SD9203144Medicaid
SD9203144Medicaid
SDSD0563OtherLIC.# FOR DEREK ALLMER
SDSD0553OtherLIC.# FOR DAWN WATTENHOFE
SD9200982Medicaid