Healthcare Provider Details

I. General information

NPI: 1396974572
Provider Name (Legal Business Name): JENNIFER VAN WAGONER DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2009
Last Update Date: 10/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35401 MISSION DR
ST. IGNATIUS MT
59865
US

IV. Provider business mailing address

P.O. BOX 880
ST. IGNATIUS MT
59865
US

V. Phone/Fax

Practice location:
  • Phone: 406-745-3525
  • Fax: 406-745-3529
Mailing address:
  • Phone: 406-745-3525
  • Fax: 406-745-3529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5912
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5912
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: