Provider Demographics
NPI:1043373012
Name:GLACIER ORAL AND MAXILLOFACIAL SURGERY PC
Entity Type:Organization
Organization Name:GLACIER ORAL AND MAXILLOFACIAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MD
Authorized Official - Phone:406-862-5656
Mailing Address - Street 1:711 13TH STR E
Mailing Address - Street 2:STE 101
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937
Mailing Address - Country:US
Mailing Address - Phone:406-862-5656
Mailing Address - Fax:406-862-6155
Practice Address - Street 1:711 13TH STR E
Practice Address - Street 2:STE 101
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937
Practice Address - Country:US
Practice Address - Phone:406-862-5656
Practice Address - Fax:406-862-6155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT11198261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0130186Medicaid
MT95296OtherBLUE CROSS BLUE SHIELD ID
MT2235OtherMONTANA DENTAL LICENSE #
MT11198OtherMONTANA MEDICAL LICENSE #
MTBW6535617OtherDEA NUMBER