Healthcare Provider Details

I. General information

NPI: 1740546100
Provider Name (Legal Business Name): ELKHORN FAMILY DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 04/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 NORTH MAIN STREET
BOULDER MT
59632-0512
US

IV. Provider business mailing address

PO BOX 512 211 NORTH MAIN STREET
BOULDER MT
59632-0512
US

V. Phone/Fax

Practice location:
  • Phone: 406-225-4222
  • Fax: 406-225-4222
Mailing address:
  • Phone: 406-225-4222
  • Fax: 406-225-4222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2386
License Number StateMT

VIII. Authorized Official

Name: DR. CHARISSA FOSTER MARTIN
Title or Position: OWNER
Credential: DMD
Phone: 406-225-4222