Provider Demographics
NPI:1033263066
Name:KULAGA, THEODORE KEITH (DDS)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:KEITH
Last Name:KULAGA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047-3456
Mailing Address - Country:US
Mailing Address - Phone:406-222-6061
Mailing Address - Fax:406-222-6062
Practice Address - Street 1:422 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047-3456
Practice Address - Country:US
Practice Address - Phone:406-222-6061
Practice Address - Fax:406-222-6062
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT5510754OtherCHIP
MT0124683Medicaid