=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699459453
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CODY FORKAN DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2023
-----------------------------------------------------
Last Update Date | 04/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2425 CORNELL AVE
-----------------------------------------------------
City | BUTTE
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59701-3848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-494-7919
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 44 ANAVISTA RD
-----------------------------------------------------
City | ANACONDA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59711-2056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-560-6583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 25984
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 25984
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------