Organization
MISSOULA PEDIATRIC DENTISTRY PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. PAUL LEONARD TIEDE (BUSINESS MANAGER)
(406) 541-7334
Entity
Organization
Contact information
Practice address
1300 SOUTH RESERVE ST, SUITE B, MISSOULA, MT 59801
(406) 541-7334
(406) 541-7338
Mailing address
1300 SOUTH RESERVE ST, SUITE B, MISSOULA, MT 59801
(406) 541-7334
(406) 541-7338
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
MT2212
MT
1223G0001X
General Practice Dentistry
MT2229
MT
1223P0221X
Pediatric Dentistry
Primary
MT2151
MT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1558308221
—
MT
01
—
5512641
CHIPS
MT
Enumeration date
12/06/2007
Last updated
01/31/2014
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