Healthcare Provider Details

I. General information

NPI: 1750418588
Provider Name (Legal Business Name): LAURA ANTHONIA UNDRAITIS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA ANTHONIA RADDATZ DDS

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 12/11/2023
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 COMMONS LOOP A- MONTANA DENTAL DESIGNS
KALISPELL MT
59901-1912
US

IV. Provider business mailing address

195 COMMONS LOOP A- MONTANA DENTAL DESIGNS
KALISPELL MT
59901-1912
US

V. Phone/Fax

Practice location:
  • Phone: 406-755-5280
  • Fax: 406-752-7679
Mailing address:
  • Phone: 406-755-5280
  • Fax: 406-752-7679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number1979
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1979
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: