Healthcare Provider Details

I. General information

NPI: 1497917132
Provider Name (Legal Business Name): GRANT MATTHEW WISWELL MD, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 406-541-2180
  • Fax: 406-541-2188
Mailing address:
  • Phone: 406-541-2180
  • Fax: 406-541-2188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number12707
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2433
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2433
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: