# SAPPHIRE DENTAL GROUP, PC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Family Dental Group
- **Organization subpart:** No

## Provider details

- **NPI number:** 1619970076
- **Authorized official:** MR. SHAWN D. MODULA (GENERAL MANAGER)
- **Authorized official phone:** (406) 541-2889

## Contact information

- **Practice address:** FAMILY DENTAL GROUP, 2901 BROOKS ST., MISSOULA, MT 59801-7722
- **Practice address phone:** (406) 541-2886
- **Practice address fax:** (406) 541-2889
- **Mailing address:** FAMILY DENTAL GROUP, 2901 BROOKS ST., MISSOULA, MT 59801-7722
- **Mailing address phone:** (406) 541-2886
- **Mailing address fax:** (406) 541-2889

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | 2016 | MT | Yes |

## Other

- **Enumeration date:** 05/31/2005
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 0000020164 | BLUE CROSS BLUE SHIELD | MT |
| 05 | — | 5510771 | — | MT |