Healthcare Provider Details

I. General information

NPI: 1255620928
Provider Name (Legal Business Name): MISSOULA ORAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 S RESERVE ST SUITE C
MISSOULA MT
59801-7644
US

IV. Provider business mailing address

3020 S RESERVE ST SUITE C
MISSOULA MT
59801-7644
US

V. Phone/Fax

Practice location:
  • Phone: 406-552-9970
  • Fax:
Mailing address:
  • Phone: 406-552-9970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number2433
License Number StateMT

VIII. Authorized Official

Name: DR. GRANT MATTHEW WISWELL
Title or Position: OWNER/SURGEON
Credential: M.D,, D.D.S
Phone: 406-552-9970