Provider Demographics
NPI:1073073268
Name:THE VINE KIDS DENTAL
Entity Type:Organization
Organization Name:THE VINE KIDS DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JI MIN
Authorized Official - Middle Name:
Authorized Official - Last Name:YOCHIM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:406-404-8463
Mailing Address - Street 1:PO BOX 4708
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59772-4708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 N 7TH AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3304
Practice Address - Country:US
Practice Address - Phone:406-404-8463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1578899886Medicaid