=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205626637
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLASGOW DENTAL CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2025
-----------------------------------------------------
Last Update Date | 05/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1009 6TH AVE N
-----------------------------------------------------
City | GLASGOW
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59230-1659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-288-2656
-----------------------------------------------------
Fax | 406-228-2656
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 809
-----------------------------------------------------
City | GLASGOW
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59230-0809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-288-2656
-----------------------------------------------------
Fax | 406-228-2656
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOLYNN M REYLINGCAPDEVILLE
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 816-617-2471
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------