Provider Demographics
NPI:1053462341
Name:BRUK P. WEYMOUTH, DDS, PC
Entity Type:Organization
Organization Name:BRUK P. WEYMOUTH, DDS, PC
Other - Org Name:FAMILY DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:WEYMOUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-727-1006
Mailing Address - Street 1:PO BOX 7050
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59406-7050
Mailing Address - Country:US
Mailing Address - Phone:406-727-1006
Mailing Address - Fax:406-727-1008
Practice Address - Street 1:3224 10TH AVE S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-3449
Practice Address - Country:US
Practice Address - Phone:406-727-1006
Practice Address - Fax:406-727-1008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT17861223G0001X
MT20911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT5512386OtherDR WEYMOUTH CHIP ID #
MT0112659Medicaid
MT0112829Medicaid
MT5512284OtherDR BOLLWITT CHIP ID#