1164935573 NPI number — MONTANA ROOTS DENTAL CARE PLLC

Table of content: (NPI 1164935573)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164935573 NPI number — MONTANA ROOTS DENTAL CARE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONTANA ROOTS DENTAL CARE PLLC
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:
1164935573
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2744 COLONIAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HELENA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59601-4947
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-442-0282
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2744 COLONIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HELENA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59601-4947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-442-0282
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/07/2017

Additional Information

Authorized Official

Authorized Official Last Name:
TRUESDELL
Authorized Official First Name:
BRANDI
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
406-442-0282

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  2455 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 2455 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2455 . This is a "LICENSE" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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