Healthcare Provider Details

I. General information

NPI: 1679911044
Provider Name (Legal Business Name): NORTHWEST DENTURE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2013
Last Update Date: 06/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 S HIGGINS AVE
MISSOULA MT
59801-6762
US

IV. Provider business mailing address

2021 S HIGGINS AVE
MISSOULA MT
59801-6762
US

V. Phone/Fax

Practice location:
  • Phone: 406-542-0609
  • Fax: 406-721-7617
Mailing address:
  • Phone: 406-542-0609
  • Fax: 406-721-7617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code292200000X
TaxonomyDental Laboratory
License NumberDTR MT 18
License Number StateMT

VIII. Authorized Official

Name: MR. KENNETH SCOTT MACPHERSON
Title or Position: OWNER
Credential: LICENSED DENTURIST
Phone: 406-542-0609