MEDICARE: SMILE MISSOULA PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2474	MT
2	1223G0001X	General Practice Dentistry	1424	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5511480	OTHER	MT	CHIP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225306749
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE MISSOULA PC

Provider Business Mailing Address
First Line	:	300 BEN HOGAN DR
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59803-2419
Country	:	US
Telephone Number	:	406-721-2830
Fax Number	:	406-549-5053

Provider Business Practice Location Address
First Line	:	237 SW HIGGINS AVE
Second Line	:	STE C
City	:	MISSOULA
State	:	MT
Zip	:	59803-1485
Country	:	US
Telephone Number	:	406-721-2830
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GEORGE M. OLSEN
Credential	:	DDS
Telephone Number	:	406-721-2830

Provider Enumeration Date	:	12/12/2011
Last Update Date	:	02/24/2012

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Directions to “SMILE MISSOULA PC ” Practice Location

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