Healthcare Provider Details

I. General information

NPI: 1558308221
Provider Name (Legal Business Name): SUSAN BON TIEDE D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 S RESERVE ST STE D SUITE B
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: 406-541-7337
  • Fax: 406-541-7338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number5820
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2151
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: