Healthcare Provider Details

I. General information

NPI: 1538563564
Provider Name (Legal Business Name): BAGNELL DENTAL CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2014
Last Update Date: 10/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15276 BELKER LANE
FRENCHTOWN MT
59834
US

IV. Provider business mailing address

15276 BELKER LANE
FRENCHTOWN MT
59834
US

V. Phone/Fax

Practice location:
  • Phone: 406-626-5520
  • Fax:
Mailing address:
  • Phone: 406-626-5520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1951
License Number StateMT

VIII. Authorized Official

Name: TIMOTHY HOWARD BAGNELL
Title or Position: OWNER/DENTIST
Credential: D. D. S.
Phone: 406-626-5520