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General NPI Number Information
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NPI Number | 1912120817
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Entity Type | Organization
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Legal Business Name | STATE OF MONTANA
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Dates
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Enumeration Date | 04/10/2007
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Last Update Date | 01/25/2011
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Provider Practice Location Address
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Address Line | 1400 BROADWAY RM A116
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City | HELENA
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State | MT
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Zip | 59620
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Country | US
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Telephone | 406-444-3529
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Fax | 406-444-2750
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Provider Business Mailing Address
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Address Line | PO BOX 202951
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City | HELENA
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State | MT
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Zip | 59620-2951
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Country | US
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Telephone | 406-444-3529
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Fax | 406-444-2750
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Authorized Official
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Title or Position | BILLING AGENT
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Name | MICHELE S O'DONNELL
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Credential |
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Telephone | 406-444-3529
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS0112X
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Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
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License Number |
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License Number State | MT
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