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General NPI Number Information
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NPI Number | 1023463320
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Entity Type | Organization
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Legal Business Name | LEGENDARY SMILES, P.C.
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Dates
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Enumeration Date | 04/25/2016
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Last Update Date | 04/25/2016
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Provider Practice Location Address
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Address Line | 109 5TH ST SW
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City | WATFORD CITY
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State | ND
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Zip | 58854-7135
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Country | US
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Telephone | 701-842-4474
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Fax | 701-842-4472
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Provider Business Mailing Address
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Address Line | 109 5TH ST SW PO BOX 486
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City | WATFORD CITY
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State | ND
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Zip | 58854-7135
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Country | US
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Telephone | 701-842-4474
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Fax | 701-842-4472
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. MONTY STEWART BULZOMI
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Credential | D.D.S
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Telephone | 701-842-4474
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 2238
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License Number State | ND
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