Healthcare Provider Details

I. General information

NPI: 1063563443
Provider Name (Legal Business Name): RONALD B POTTHOFF DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 COMMONS LOOP STE A
KALISPELL MT
59901-1912
US

IV. Provider business mailing address

195 COMMONS LOOP STE A
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 TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1942
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: