Healthcare Provider Details

I. General information

NPI: 1568857100
Provider Name (Legal Business Name): KALISPELL DENTURE STUDIO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2015
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 6TH AVE E STE 5
KALISPELL MT
59901-5005
US

IV. Provider business mailing address

725 6TH AVE E STE 5
KALISPELL MT
59901-5005
US

V. Phone/Fax

Practice location:
  • Phone: 406-314-4892
  • Fax: 406-314-4893
Mailing address:
  • Phone: 406-314-4892
  • Fax: 406-314-4893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License Number
License Number State

VIII. Authorized Official

Name: KELLY JENSEN
Title or Position: DENTURIST/OWNER
Credential:
Phone: 406-314-4892