MEDICARE: SMILE MONTANA URGENT DENTAL CENTER

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	1223D0001X	Public Health Dentistry	2463	MT

General Provider Information

NPI Number	:	1619413184
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE MONTANA URGENT DENTAL CENTER

Provider Business Mailing Address
First Line	:	115 COMMONS WAY STE 102
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-1906
Country	:	US
Telephone Number	:	406-892-2104
Fax Number	:	406-892-1422

Provider Business Practice Location Address
First Line	:	115 COMMONS WAY STE 102
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-1906
Country	:	US
Telephone Number	:	406-892-2104
Fax Number	:	406-892-1422

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN F MILLER
Credential	:	D.D.S.
Telephone Number	:	406-892-2104

Provider Enumeration Date	:	01/09/2017
Last Update Date	:	01/09/2017

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