=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003008251
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BIGFORK DENTAL CENTER, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2007
-----------------------------------------------------
Last Update Date | 08/13/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8289 MT HIGHWAY 35
-----------------------------------------------------
City | BIGFORK
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59911-3518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-837-5611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8289 MT HIGHWAY 35
-----------------------------------------------------
City | BIGFORK
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59911-3518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GARY MCCRUMMEN
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 406-837-5611
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 1636
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------