Provider Demographics
NPI:1235268673
Name:LISTER, JAY Q (DDS)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:Q
Last Name:LISTER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2398 LOVE LN
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-9769
Mailing Address - Country:US
Mailing Address - Phone:907-978-0631
Mailing Address - Fax:
Practice Address - Street 1:103 W JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:BELGRADE
Practice Address - State:MT
Practice Address - Zip Code:59714-4404
Practice Address - Country:US
Practice Address - Phone:406-388-4064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT22331223G0001X
WI5404-0151223G0001X
AK10961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice