Healthcare Provider Details

I. General information

NPI: 1629133186
Provider Name (Legal Business Name): LOLO DENTAL CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 TYLER WAY
LOLO MT
59847
US

IV. Provider business mailing address

PO BOX 725
LOLO MT
59847
US

V. Phone/Fax

Practice location:
  • Phone: 406-273-0490
  • Fax: 406-273-7969
Mailing address:
  • Phone: 406-273-0490
  • Fax: 406-273-7969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateMT

VIII. Authorized Official

Name: MARIE ROSE HILLBERRY
Title or Position: VICE PRESIDENT LOLODENTAL CLINIC PC
Credential:
Phone: 406-273-0490