Provider Demographics
NPI:1497992424
Name:GLACIER DENTAL CLINIC
Entity Type:Organization
Organization Name:GLACIER DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SYLVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERKRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-873-5670
Mailing Address - Street 1:519 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CUT BANK
Mailing Address - State:MT
Mailing Address - Zip Code:59427-3015
Mailing Address - Country:US
Mailing Address - Phone:406-873-5670
Mailing Address - Fax:406-873-2256
Practice Address - Street 1:140 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CUT BANK
Practice Address - State:MT
Practice Address - Zip Code:59427-3298
Practice Address - Country:US
Practice Address - Phone:406-873-5222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GLACIER COMMUNITY HEALTH CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1843261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT730418Medicaid
000084542OtherMEDICARE PART B
000084542OtherMEDICARE PART B