Healthcare Provider Details

I. General information

NPI: 1720081201
Provider Name (Legal Business Name): TOM RICHARD LIDAHL D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 N MAIN ST
PLENTYWOOD MT
59254-1843
US

IV. Provider business mailing address

223 N MAIN ST
PLENTYWOOD MT
59254-1843
US

V. Phone/Fax

Practice location:
  • Phone: 406-765-2700
  • Fax: 406-765-1514
Mailing address:
  • Phone: 406-765-2700
  • Fax: 406-765-1514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1327
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD10463
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: