Healthcare Provider Details

I. General information

NPI: 1043373012
Provider Name (Legal Business Name): GLACIER ORAL AND MAXILLOFACIAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 13TH STR E STE 101
WHITEFISH MT
59937
US

IV. Provider business mailing address

711 13TH STR E STE 101
WHITEFISH MT
59937
US

V. Phone/Fax

Practice location:
  • Phone: 406-862-5656
  • Fax: 406-862-6155
Mailing address:
  • Phone: 406-862-5656
  • Fax: 406-862-6155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number11198
License Number StateMT

VIII. Authorized Official

Name: BERNADETTE L WILSON
Title or Position: PRESIDENT
Credential: DDS MD
Phone: 406-862-5656