Healthcare Provider Details

I. General information

NPI: 1689322067
Provider Name (Legal Business Name): DR. KYLE BAGNELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2022
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 DOC KIMBALL WAY
BIGFORK MT
59911-6491
US

IV. Provider business mailing address

33 DOC KIMBALL WAY
BIGFORK MT
59911-6491
US

V. Phone/Fax

Practice location:
  • Phone: 406-261-6430
  • Fax:
Mailing address:
  • Phone: 406-261-6430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN-DEN-LIC-23638
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: