Provider Demographics
NPI:1225306749
Name:SMILE MISSOULA PC
Entity Type:Organization
Organization Name:SMILE MISSOULA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:M
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:406-721-2830
Mailing Address - Street 1:300 BEN HOGAN DR
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-2419
Mailing Address - Country:US
Mailing Address - Phone:406-721-2830
Mailing Address - Fax:406-549-5053
Practice Address - Street 1:237 SW HIGGINS AVE
Practice Address - Street 2:STE C
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-1485
Practice Address - Country:US
Practice Address - Phone:406-721-2830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-12
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT14241223G0001X
MT24741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT5511480OtherCHIP
MT1101-62Medicaid