Provider Demographics
NPI:1477757458
Name:DERNBACH, DANIEL ADAM (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:ADAM
Last Name:DERNBACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 12TH AVE N
Mailing Address - Street 2:SUITE 315W
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-7506
Mailing Address - Country:US
Mailing Address - Phone:406-237-8270
Mailing Address - Fax:406-237-8275
Practice Address - Street 1:2900 12TH AVE N
Practice Address - Street 2:SUITE 315W
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-7506
Practice Address - Country:US
Practice Address - Phone:406-237-8270
Practice Address - Fax:406-237-8275
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3370174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTC64049Medicare UPIN