Healthcare Provider Details

I. General information

NPI: 1366088098
Provider Name (Legal Business Name): WESLEY JAMES CARNAHAN LD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2019
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 STOCKYARD RD STE E4
MISSOULA MT
59808-1510
US

IV. Provider business mailing address

2825 STOCKYARD RD STE E4
MISSOULA MT
59808-1510
US

V. Phone/Fax

Practice location:
  • Phone: 406-317-1314
  • Fax:
Mailing address:
  • Phone: 406-317-1314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License Number15312
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: