Healthcare Provider Details

I. General information

NPI: 1437205119
Provider Name (Legal Business Name): MISTY DAWN ROBERTSON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 N PERIMETER ROAD
MALMSTROM AFB MT
59402
US

IV. Provider business mailing address

PO BOX 1025
GREAT FALLS MT
59403-1025
US

V. Phone/Fax

Practice location:
  • Phone: 406-731-2846
  • Fax:
Mailing address:
  • Phone: 406-781-4746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number760
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number1125
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2004015668
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: