MEDICARE: TARA ELIZABETH GILBREATH DDS

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	122300000X	Dentist	2355	MT

General Provider Information

NPI Number	:	1710119896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA ELIZABETH GILBREATH DDS

Provider Business Mailing Address
First Line	:	820 SAMPSON ST
Second Line	:
City	:	BUTTE
State	:	MT
Zip	:	59701-3208
Country	:	US
Telephone Number	:	406-494-7080
Fax Number	:	406-494-4634

Provider Business Practice Location Address
First Line	:	820 SAMPSON ST
Second Line	:
City	:	BUTTE
State	:	MT
Zip	:	59701-3208
Country	:	US
Telephone Number	:	406-494-7080
Fax Number	:	406-494-4634

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2009
Last Update Date	:	08/30/2013

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