Provider Demographics
NPI:1558507855
Name:DR. CONNIE SMALL
Entity Type:Organization
Organization Name:DR. CONNIE SMALL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:406-755-4127
Mailing Address - Street 1:1050 N MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3542
Mailing Address - Country:US
Mailing Address - Phone:406-755-4127
Mailing Address - Fax:406-755-4034
Practice Address - Street 1:1050 N MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3542
Practice Address - Country:US
Practice Address - Phone:406-755-4127
Practice Address - Fax:406-755-4034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1758122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1164508123Medicaid
MT1457323719Medicaid