Provider Demographics
NPI:1376813543
Name:LILLY, PAMELA M (DDS)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:M
Last Name:LILLY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 WISCONSIN AVE STE C
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-2172
Mailing Address - Country:US
Mailing Address - Phone:406-862-8180
Mailing Address - Fax:406-862-8186
Practice Address - Street 1:905 WISCONSIN AVE STE C
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-2172
Practice Address - Country:US
Practice Address - Phone:406-862-8180
Practice Address - Fax:406-862-8186
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT19001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice