Provider Demographics
NPI:1326706201
Name:MONTANA CHILDRENS DENTISTRY PLLC
Entity Type:Organization
Organization Name:MONTANA CHILDRENS DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DELISLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:702-339-7274
Mailing Address - Street 1:116 GLACIER DR STE 107
Mailing Address - Street 2:
Mailing Address - City:LOLO
Mailing Address - State:MT
Mailing Address - Zip Code:59847-9343
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 GLACIER DR STE 107
Practice Address - Street 2:
Practice Address - City:LOLO
Practice Address - State:MT
Practice Address - Zip Code:59847-9343
Practice Address - Country:US
Practice Address - Phone:702-339-7274
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty