Provider Demographics
NPI:1578220463
Name:POWELL, DERIK (DDS)
Entity Type:Individual
Prefix:DR
First Name:DERIK
Middle Name:
Last Name:POWELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 12TH AVE S STE 109
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-5099
Mailing Address - Country:US
Mailing Address - Phone:406-761-1837
Mailing Address - Fax:
Practice Address - Street 1:2300 12TH AVE S STE 109
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5099
Practice Address - Country:US
Practice Address - Phone:406-761-1837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-26
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT214661223G0001X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental