Provider Demographics
NPI:1083791784
Name:GANNON, MOLLY ROWE (DDS, PC)
Entity Type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:ROWE
Last Name:GANNON
Suffix:
Gender:F
Credentials:DDS, PC
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:R
Other - Last Name:GANNON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:D D S P C
Mailing Address - Street 1:512 OLD CORVALLIS RD
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-3131
Mailing Address - Country:US
Mailing Address - Phone:406-363-1211
Mailing Address - Fax:406-363-1212
Practice Address - Street 1:512 OLD CORVALLIS RD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-3131
Practice Address - Country:US
Practice Address - Phone:406-363-1211
Practice Address - Fax:406-363-1212
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT20661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT20664OtherBLUE CROSS PROVIDER NUMBE
MT5511948Medicaid
MT5511948Medicaid