Healthcare Provider Details

I. General information

NPI: 1053273011
Provider Name (Legal Business Name): 12 ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2025
Last Update Date: 11/28/2025
Certification Date: 11/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 BRUYER WAY
KALISPELL MT
59901-6305
US

IV. Provider business mailing address

34 BRUYER WAY
KALISPELL MT
59901-6305
US

V. Phone/Fax

Practice location:
  • Phone: 406-752-8686
  • Fax:
Mailing address:
  • Phone: 406-752-8686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. KURTIS CRANDELL BRAY
Title or Position: OWNER
Credential: DMD
Phone: 406-370-5227