Healthcare Provider Details

I. General information

NPI: 1942483524
Provider Name (Legal Business Name): MISSOULA PEDIATRIC DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 SOUTH RESERVE ST SUITE B
MISSOULA MT
59801
US

IV. Provider business mailing address

1300 SOUTH RESERVE ST SUITE B
MISSOULA MT
59801
US

V. Phone/Fax

Practice location:
  • Phone: 406-541-7334
  • Fax: 406-541-7338
Mailing address:
  • Phone: 406-541-7334
  • Fax: 406-541-7338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberMT2229
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberMT2212
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberMT2151
License Number StateMT

VIII. Authorized Official

Name: MR. PAUL LEONARD TIEDE
Title or Position: BUSINESS MANAGER
Credential:
Phone: 406-541-7334