Healthcare Provider Details

I. General information

NPI: 1205183852
Provider Name (Legal Business Name): MISSOULA PEDITRIC DENTISTRY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 08/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 S RESERVE ST STE D
MISSOULA MT
59801-7652
US

IV. Provider business mailing address

3020 S RESERVE ST STE D
MISSOULA MT
59801-7652
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 TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number4170
License Number StateMT

VIII. Authorized Official

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