Provider Demographics
NPI:1407116338
Name:FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY MONTANA PC
Entity Type:Organization
Organization Name:FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY MONTANA PC
Other - Org Name:COSMETIC SURGICAL ARTS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:O
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD DDS
Authorized Official - Phone:406-549-6600
Mailing Address - Street 1:805 S RESERVE ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-2104
Mailing Address - Country:US
Mailing Address - Phone:406-549-6600
Mailing Address - Fax:406-549-1511
Practice Address - Street 1:805 S RESERVE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-2104
Practice Address - Country:US
Practice Address - Phone:406-549-6600
Practice Address - Fax:406-549-1511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-25
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12580261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
261QA1903XOtherTAXONOMY
MT60882OtherBLUE CROSS BLUE SHIELD