Organization
GLACIER ORAL AND MAXILLOFACIAL SURGERY PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BERNADETTE L WILSON DDS MD (PRESIDENT)
(406) 862-5656
Entity
Organization
Contact information
Practice address
711 13TH STR E, STE 101, WHITEFISH, MT 59937
(406) 862-5656
(406) 862-6155
Mailing address
711 13TH STR E, STE 101, WHITEFISH, MT 59937
(406) 862-5656
(406) 862-6155
Taxonomy
Speciality
Code
Description
License number
State
261QS0112X
Oral and Maxillofacial Surgery Clinic/Center
Primary
11198
MT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0130186
—
MT
01
—
11198
MONTANA MEDICAL LICENSE #
MT
01
—
2235
MONTANA DENTAL LICENSE #
MT
01
—
95296
BLUE CROSS BLUE SHIELD ID
MT
Enumeration date
12/19/2006
Last updated
03/07/2023
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