1215298195 NPI number — MISSOULA GENERAL DENTISTRY, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215298195 NPI number — MISSOULA GENERAL DENTISTRY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSOULA GENERAL DENTISTRY, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215298195
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3020 S RESERVE ST STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISSOULA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59801-7652
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-541-3585
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3020 S RESERVE ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MISSOULA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59801-7652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-541-3585
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/06/2012

Additional Information

Authorized Official

Authorized Official Last Name:
KINNEE
Authorized Official First Name:
TERRI
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
GENERAL DENTIST
Authorized Official Telephone Number:
406-541-3585

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: MT2438 . This is a "STATE OF MONTANA" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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