Provider Demographics
NPI:1619970076
Name:SAPPHIRE DENTAL GROUP, PC
Entity Type:Organization
Organization Name:SAPPHIRE DENTAL GROUP, PC
Other - Org Name:FAMILY DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MODULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-541-2889
Mailing Address - Street 1:FAMILY DENTAL GROUP
Mailing Address - Street 2:2901 BROOKS ST.
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-7722
Mailing Address - Country:US
Mailing Address - Phone:406-541-2886
Mailing Address - Fax:406-541-2889
Practice Address - Street 1:FAMILY DENTAL GROUP
Practice Address - Street 2:2901 BROOKS ST.
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-7722
Practice Address - Country:US
Practice Address - Phone:406-541-2886
Practice Address - Fax:406-541-2889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT20161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT5510771Medicaid
MT0000020164OtherBLUE CROSS BLUE SHIELD
MT5510771Medicaid
MT0000020164OtherBLUE CROSS BLUE SHIELD