Organization
MISSOULA PEDIATRIC DENTISTRY, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PAUL LEONARD TIEDE (BUSINESS MANAGER)
(406) 541-7334
Entity
Organization
Contact information
Practice address
3020 S RESERVE ST, SUITE D, MISSOULA, MT 59801-7652
(406) 541-7334
(406) 541-7338
Mailing address
3020 S RESERVE ST, SUITE D, MISSOULA, MT 59801-7652
(406) 541-7334
(406) 541-7338
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
MT2151
MT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1942483524
—
MT
Enumeration date
11/12/2013
Last updated
11/12/2013
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