Healthcare Provider Details

I. General information

NPI: 1669234829
Provider Name (Legal Business Name): MT SDS III, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2024
Last Update Date: 01/24/2024
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1256 N MERIDIAN RD STE A
KALISPELL MT
59901-3006
US

IV. Provider business mailing address

1610 54TH AVE N STE 205
NASHVILLE TN
37209-1442
US

V. Phone/Fax

Practice location:
  • Phone: 406-752-1131
  • Fax:
Mailing address:
  • Phone: 615-678-0759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CHARLOTTE E VIAL
Title or Position: DIREC OF CRED AND PROV REL
Credential:
Phone: 504-638-0303