Provider Demographics
NPI:1578993531
Name:MISSOULA PEDIATRIC DENTISTRY, PLLC
Entity Type:Organization
Organization Name:MISSOULA PEDIATRIC DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:TIEDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-541-7334
Mailing Address - Street 1:3020 S RESERVE ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-7652
Mailing Address - Country:US
Mailing Address - Phone:406-541-7334
Mailing Address - Fax:406-541-7338
Practice Address - Street 1:3020 S RESERVE ST
Practice Address - Street 2:SUITE D
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-7652
Practice Address - Country:US
Practice Address - Phone:406-541-7334
Practice Address - Fax:406-541-7338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT21511223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1942483524Medicaid