MEDICARE: SAPPHIRE DENTAL GROUP, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2016	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0000020164	OTHER	MT	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1619970076
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAPPHIRE DENTAL GROUP, PC

Provider Business Mailing Address
First Line	:	FAMILY DENTAL GROUP
Second Line	:	2901 BROOKS ST.
City	:	MISSOULA
State	:	MT
Zip	:	59801-7722
Country	:	US
Telephone Number	:	406-541-2886
Fax Number	:	406-541-2889

Provider Business Practice Location Address
First Line	:	FAMILY DENTAL GROUP
Second Line	:	2901 BROOKS ST.
City	:	MISSOULA
State	:	MT
Zip	:	59801-7722
Country	:	US
Telephone Number	:	406-541-2886
Fax Number	:	406-541-2889

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	MR. SHAWN D. MODULA
Credential	:
Telephone Number	:	406-541-2889

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	08/22/2020

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