Provider Demographics
NPI:1225274756
Name:KOOTENAI FAMILY DENTISTRY
Entity Type:Organization
Organization Name:KOOTENAI FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:MENDENHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:406-293-4116
Mailing Address - Street 1:PO BOX 1379
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-1379
Mailing Address - Country:US
Mailing Address - Phone:406-293-4116
Mailing Address - Fax:406-293-6645
Practice Address - Street 1:204 E 6TH ST
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-2052
Practice Address - Country:US
Practice Address - Phone:406-293-4116
Practice Address - Fax:406-293-6645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1984122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty