=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023181260
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NANETTE B.I. AULT, D.D.S., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 619 SW HIGGINS AVE STE G
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59803-1430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-549-4867
-----------------------------------------------------
Fax | 406-721-3692
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 1131
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-549-4867
-----------------------------------------------------
Fax | 406-721-3692
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PERIODONTIST
-----------------------------------------------------
Name | DR. NANETTE B.I. AULT
-----------------------------------------------------
Credential | D.D.S., P.C.
-----------------------------------------------------
Telephone | 406-549-4867
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 2089
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------