Provider Demographics
NPI:1154460574
Name:JOHN B MCCOLLUM DDS PC
Entity Type:Organization
Organization Name:JOHN B MCCOLLUM DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:MCCOLLUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:406-683-5125
Mailing Address - Street 1:PO BOX 1255
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:MT
Mailing Address - Zip Code:59725-1255
Mailing Address - Country:US
Mailing Address - Phone:406-683-5125
Mailing Address - Fax:406-683-5126
Practice Address - Street 1:110 SOUTH IDAHO STREET
Practice Address - Street 2:STATE BANK BUILDING
Practice Address - City:DILLON
Practice Address - State:MT
Practice Address - Zip Code:59725
Practice Address - Country:US
Practice Address - Phone:406-683-5125
Practice Address - Fax:406-683-5126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1108122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0132587Medicaid