NPI Code Detail JSON Logo

1629636097 NPI number — DEREK CHARLES METTENBRINK DDS

NPI Number: 1629636097
Health Care Provider/Practitioner: DEREK CHARLES METTENBRINK DDS

Information about “1629636097” NPI (DEREK CHARLES METTENBRINK DDS) exists in 1629636097 in HTML format HTML  |  1629636097 in plain Text format TXT  |  1629636097 in PDF (Portable Document Format) PDF  |  1629636097 in an XML format XML  formats.

NPI Number : 1629636097 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1629636097",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "METTENBRINK",
    "FirstName": "DEREK",
    "MiddleName": "CHARLES",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "DDS",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "4256 DIAGON LN",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "MISSOULA",
    "MailingAddressStateName": "MT",
    "MailingAddressPostalCode": "59808-5306",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "308-380-5938",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "3020 S RESERVE ST STE D",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "MISSOULA",
    "PracticeLocationAddressStateName": "MT",
    "PracticeLocationAddressPostalCode": "59801-7652",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "406-541-7337",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "05/31/2019",
    "LastUpdateDate": "01/07/2022",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "1223P0221X",
          "TaxonomyName": "Pediatric Dentistry",
          "LicenseNumber": "7535",
          "LicenseNumberStateCode": "NE",
          "PrimaryTaxonomySwitch": "Y"
        },
        {
          "TaxonomyCode": "1223P0221X",
          "TaxonomyName": "Pediatric Dentistry",
          "LicenseNumber": "DEN-DEN-LIC-19245",
          "LicenseNumberStateCode": "MT",
          "PrimaryTaxonomySwitch": "N"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

Copyright © 2007-2025 Data Labs Health. All rights reserved.