Healthcare Provider Details

I. General information

NPI: 1912921594
Provider Name (Legal Business Name): TERRY KLISE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2603 DEER CANYON CT
MISSOULA MT
59808-8638
US

IV. Provider business mailing address

2603 DEER CANYON CT
MISSOULA MT
59808-8638
US

V. Phone/Fax

Practice location:
  • Phone: 406-529-2612
  • Fax: 406-721-1126
Mailing address:
  • Phone: 406-529-2612
  • Fax: 406-721-1126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number2229
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2229
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: