MEDICARE: DR. LAURA ANTHONIA UNDRAITIS DDS

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	1223D0001X	Public Health Dentistry	1979	MT
2	1223G0001X	General Practice Dentistry	1979	MT

General Provider Information

NPI Number	:	1750418588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURA ANTHONIA UNDRAITIS DDS

Provider Business Mailing Address
First Line	:	195 COMMONS LOOP A- MONTANA DENTAL DESIGNS
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-1912
Country	:	US
Telephone Number	:	406-755-5280
Fax Number	:	406-752-7679

Provider Business Practice Location Address
First Line	:	195 COMMONS LOOP A- MONTANA DENTAL DESIGNS
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-1912
Country	:	US
Telephone Number	:	406-755-5280
Fax Number	:	406-752-7679

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	12/11/2023

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