Healthcare Provider Details

I. General information

NPI: 1629636097
Provider Name (Legal Business Name): DEREK CHARLES METTENBRINK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 01/07/2022
Certification Date: 01/07/2022
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

4256 DIAGON LN
MISSOULA MT
59808-5306
US

V. Phone/Fax

Practice location:
  • Phone: 406-541-7337
  • Fax:
Mailing address:
  • Phone: 308-380-5938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7535
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDEN-DEN-LIC-19245
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: