Provider Demographics
NPI:1508145913
Name:COLUMBIA FALLS FAMILY DENTAL CENTER PC
Entity Type:Organization
Organization Name:COLUMBIA FALLS FAMILY DENTAL CENTER PC
Other - Org Name:SMILE MONTANA DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:406-892-2104
Mailing Address - Street 1:P.O. BOX 1866
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59912
Mailing Address - Country:US
Mailing Address - Phone:406-892-2104
Mailing Address - Fax:406-892-1422
Practice Address - Street 1:105 NUCLEUS AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA FALLS
Practice Address - State:MT
Practice Address - Zip Code:59912
Practice Address - Country:US
Practice Address - Phone:406-892-2104
Practice Address - Fax:406-892-1422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT24631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1265720346Medicaid