Provider Demographics
NPI:1437205119
Name:ROBERTSON, MISTY DAWN (RDH)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:DAWN
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1025
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59403-1025
Mailing Address - Country:US
Mailing Address - Phone:406-781-4746
Mailing Address - Fax:
Practice Address - Street 1:3700 N PERIMETER ROAD
Practice Address - Street 2:
Practice Address - City:MALMSTROM AFB
Practice Address - State:MT
Practice Address - Zip Code:59402
Practice Address - Country:US
Practice Address - Phone:406-731-2846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY760124Q00000X
MT1125124Q00000X
MO2004015668124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2004015668OtherDENTAL HYGIENE LICEENSE
MT1125OtherDENTAL HYGIENE LICENSE
WY760OtherDENTAL HYGIENE LICENSE