Provider Demographics
NPI:1174653372
Name:FULL CARE DENTAL PLLC
Entity Type:Organization
Organization Name:FULL CARE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:M
Authorized Official - Last Name:LAWHORN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:406-543-3777
Mailing Address - Street 1:690 SW HIGGINS AVE STE E
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-1433
Mailing Address - Country:US
Mailing Address - Phone:406-543-3777
Mailing Address - Fax:406-543-6205
Practice Address - Street 1:690 SW HIGGINS AVE STE E
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-1433
Practice Address - Country:US
Practice Address - Phone:406-543-3777
Practice Address - Fax:406-543-6205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT17441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0110903Medicaid
MT5512828OtherCHIP