Healthcare Provider Details

I. General information

NPI: 1538790142
Provider Name (Legal Business Name): MELISSA ELLEN KJOS-PETERSON RDH, LAP,CIHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2020
Last Update Date: 02/01/2020
Certification Date: 02/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 GARLAND ST
KALISPELL MT
59901-2509
US

IV. Provider business mailing address

PO BOX 8946
KALISPELL MT
59904-1946
US

V. Phone/Fax

Practice location:
  • Phone: 406-253-3770
  • Fax:
Mailing address:
  • Phone: 406-253-3770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number710
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: