=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821379009
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WESTERN MONTANA FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2011
-----------------------------------------------------
Last Update Date | 10/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 63355 US HIGHWAY 93
-----------------------------------------------------
City | RONAN
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59864-2702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-676-8880
-----------------------------------------------------
Fax | 406-676-8881
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 63355 US HIGHWAY 93
-----------------------------------------------------
City | RONAN
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59864-2702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-676-8880
-----------------------------------------------------
Fax | 406-676-8881
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. TIMOTHY HOWARD BAGNELL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 406-676-8880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 1951
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------