Healthcare Provider Details

I. General information

NPI: 1164935573
Provider Name (Legal Business Name): MONTANA ROOTS DENTAL CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2017
Last Update Date: 11/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2744 COLONIAL DR
HELENA MT
59601-4947
US

IV. Provider business mailing address

2744 COLONIAL DR
HELENA MT
59601-4947
US

V. Phone/Fax

Practice location:
  • Phone: 406-442-0282
  • Fax:
Mailing address:
  • Phone: 406-442-0282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2455
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2455
License Number StateMT

VIII. Authorized Official

Name: BRANDI M TRUESDELL
Title or Position: OFFICE MANAGER
Credential:
Phone: 406-442-0282