1457430118 NPI number — FIRST IMPRESSIONS DENTURE CLINIC LLC

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 1457430118 NPI number — FIRST IMPRESSIONS DENTURE CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIRST IMPRESSIONS DENTURE CLINIC LLC
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:
6
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:
1457430118
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 165
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLACK EAGLE
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59414-0165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-216-4746
Provider Business Mailing Address Fax Number:
406-216-4747

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 SMELTER AVE NE
Provider Second Line Business Practice Location Address:
STE #3
Provider Business Practice Location Address City Name:
GREAT FALLS
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59404-1937
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-216-4746
Provider Business Practice Location Address Fax Number:
406-216-4747
Provider Enumeration Date:
11/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CASTEEL
Authorized Official First Name:
ALLEN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
DENTURIST AND LLC MEMBER
Authorized Official Telephone Number:
406-216-4746

Provider Taxonomy Codes

  • Taxonomy code: 122400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0000030314 . This is a "BCBS" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 5512471 . This is a "CHIP" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 0150178 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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