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General NPI Number Information
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NPI Number | 1942483524
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Entity Type | Organization
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Legal Business Name | MISSOULA PEDIATRIC DENTISTRY PC
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Dates
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Enumeration Date | 12/06/2007
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Last Update Date | 01/31/2014
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Provider Practice Location Address
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Address Line | 1300 SOUTH RESERVE ST SUITE B
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City | MISSOULA
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State | MT
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Zip | 59801
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Country | US
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Telephone | 406-541-7334
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Fax | 406-541-7338
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Provider Business Mailing Address
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Address Line | 1300 SOUTH RESERVE ST SUITE B
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City | MISSOULA
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State | MT
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Zip | 59801
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Country | US
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Telephone | 406-541-7334
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Fax | 406-541-7338
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | MR. PAUL LEONARD TIEDE
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Credential |
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Telephone | 406-541-7334
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | MT2229
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License Number State | MT
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | MT2212
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License Number State | MT
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Taxonomy #3
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | MT2151
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License Number State | MT
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