Provider Demographics
NPI:1447362074
Name:ICE, DWAYNE ROBERT (OD)
Entity type:Individual
Prefix:DR
First Name:DWAYNE
Middle Name:ROBERT
Last Name:ICE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:825 COLUMBUS ST
Mailing Address - Street 2:STE E
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-4803
Mailing Address - Country:US
Mailing Address - Phone:605-343-4703
Mailing Address - Fax:605-721-7201
Practice Address - Street 1:825 COLUMBUS ST
Practice Address - Street 2:STE E
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-4803
Practice Address - Country:US
Practice Address - Phone:605-343-4703
Practice Address - Fax:605-721-7201
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDT-149152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9201450Medicaid
SD75126Medicare ID - Type Unspecified
SD4402920001Medicare NSC