Provider Demographics
NPI:1417393752
Name:WEST YELLOWSTONE DENTAL
Entity Type:Organization
Organization Name:WEST YELLOWSTONE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:R
Authorized Official - Last Name:DAVIES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-301-9841
Mailing Address - Street 1:PO BOX 1966
Mailing Address - Street 2:317 NORTH CANYON ST.
Mailing Address - City:WEST YELLOWSTONE
Mailing Address - State:MT
Mailing Address - Zip Code:59758-1966
Mailing Address - Country:US
Mailing Address - Phone:406-646-7766
Mailing Address - Fax:406-646-1066
Practice Address - Street 1:317 NORTH CANYON ST
Practice Address - Street 2:
Practice Address - City:WEST YELLOWSTONE
Practice Address - State:MT
Practice Address - Zip Code:59758-9503
Practice Address - Country:US
Practice Address - Phone:406-646-7766
Practice Address - Fax:406-646-1066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty