Healthcare Provider Details

I. General information

NPI: 1093135741
Provider Name (Legal Business Name): KYLE CHARLES SMITH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W SPRUCE ST STE J
MISSOULA MT
59802
US

IV. Provider business mailing address

601 W SPRUCE ST STE J
MISSOULA MT
59802-4047
US

V. Phone/Fax

Practice location:
  • Phone: 406-327-3350
  • Fax: 406-327-3355
Mailing address:
  • Phone: 406-327-3350
  • Fax: 406-327-3355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number66644
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: