Healthcare Provider Details

I. General information

NPI: 1861933632
Provider Name (Legal Business Name): WOJJ PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2017
Last Update Date: 03/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W KAGY BLVD STE C
BOZEMAN MT
59715-6030
US

IV. Provider business mailing address

4213 GRIMES AVE S
EDINA MN
55416-5020
US

V. Phone/Fax

Practice location:
  • Phone: 303-885-6141
  • Fax:
Mailing address:
  • Phone: 303-885-6141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number13304
License Number StateMT

VIII. Authorized Official

Name: DR. JUSTIN MATTHEW STEVENS
Title or Position: PRESIDENT
Credential: DDS
Phone: 303-885-6141