Healthcare Provider Details

I. General information

NPI: 1407116338
Provider Name (Legal Business Name): FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY MONTANA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2012
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 S RESERVE ST
MISSOULA MT
59801-2104
US

IV. Provider business mailing address

805 S RESERVE ST
MISSOULA MT
59801-2104
US

V. Phone/Fax

Practice location:
  • Phone: 406-549-6600
  • Fax: 406-549-1511
Mailing address:
  • Phone: 406-549-6600
  • Fax: 406-549-1511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number12580
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. RF JOHN HOLTZEN
Title or Position: OWNER
Credential: DMD
Phone: 406-549-6600