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General NPI Number Information
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NPI Number | 1225274756
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Entity Type | Organization
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Legal Business Name | KOOTENAI FAMILY DENTISTRY
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Dates
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Enumeration Date | 01/06/2009
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Last Update Date | 01/06/2009
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Provider Practice Location Address
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Address Line | 204 E 6TH ST
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City | LIBBY
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State | MT
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Zip | 59923-2052
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Country | US
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Telephone | 406-293-4116
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Fax | 406-293-6645
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Provider Business Mailing Address
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Address Line | PO BOX 1379
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City | LIBBY
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State | MT
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Zip | 59923-1379
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Country | US
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Telephone | 406-293-4116
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Fax | 406-293-6645
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Authorized Official
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Title or Position | OWNER
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Name | DR. RONALD E. MENDENHALL
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Credential | DDS
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Telephone | 406-293-4116
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 1984
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License Number State | MT
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