Provider Demographics
NPI:1346691201
Name:QUEEN CITY DENTAL STUDIO
Entity Type:Organization
Organization Name:QUEEN CITY DENTAL STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARISSA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:406-449-1300
Mailing Address - Street 1:1300 N MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-3507
Mailing Address - Country:US
Mailing Address - Phone:406-461-4445
Mailing Address - Fax:
Practice Address - Street 1:1300 N. MONTANA AVE
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601
Practice Address - Country:US
Practice Address - Phone:406-449-1300
Practice Address - Fax:406-449-1311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-22
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2386122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty