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General NPI Number Information
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NPI Number | 1811562051
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Entity Type | Organization
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Legal Business Name | HOMEGROWN DENTAL LLC
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Dates
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Enumeration Date | 05/20/2021
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Last Update Date | 05/20/2021
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Provider Practice Location Address
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Address Line | 2507 6TH AVE S
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City | GREAT FALLS
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State | MT
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Zip | 59405-3013
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Country | US
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Telephone | 406-760-1077
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Fax | 406-235-1106
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Provider Business Mailing Address
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Address Line | 2507 6TH AVE S
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City | GREAT FALLS
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State | MT
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Zip | 59405-3013
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Country | US
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Telephone | 406-760-1077
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Fax | 406-235-1106
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | HEATHER MOORE
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Credential | DDS
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Telephone | 406-760-1077
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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 |
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License Number State |
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