Provider Demographics
NPI:1548410327
Name:BREWER DENTAL CENTER PLLC
Entity Type:Organization
Organization Name:BREWER DENTAL CENTER PLLC
Other - Org Name:BREWER DENTAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELGIN
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:WILDE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:406-656-6100
Mailing Address - Street 1:2900 CENTRAL AVE, BLDG1
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-6686
Mailing Address - Country:US
Mailing Address - Phone:406-656-6100
Mailing Address - Fax:406-656-8726
Practice Address - Street 1:2900 CENTRAL AVE, BLDG1
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102-6686
Practice Address - Country:US
Practice Address - Phone:406-656-6100
Practice Address - Fax:406-656-8726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT16641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT113607Medicaid