Provider Demographics
NPI:1417271701
Name:HELENA DENTURE CLINIC, PLLC
Entity Type:Organization
Organization Name:HELENA DENTURE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:HANSEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:LD
Authorized Official - Phone:406-442-4899
Mailing Address - Street 1:3404 COONEY DR
Mailing Address - Street 2:STE 106
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59602-0215
Mailing Address - Country:US
Mailing Address - Phone:406-442-4899
Mailing Address - Fax:
Practice Address - Street 1:3404 COONEY DR
Practice Address - Street 2:STE 106
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59602-0215
Practice Address - Country:US
Practice Address - Phone:406-442-4899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT20122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT150093Medicaid