=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841648227
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEADOWLARK DENTAL CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2016
-----------------------------------------------------
Last Update Date | 05/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 628 SOUTH AVE W SUITE B
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59801-8020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-543-0300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 628 SOUTH AVE W SUITE B
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59801-8020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-543-0300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CYRUS MICHAEL LARSON
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 406-543-0300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 1739
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 9630
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------