Provider Demographics
NPI:1629133186
Name:LOLO DENTAL CLINIC PC
Entity Type:Organization
Organization Name:LOLO DENTAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT LOLODENTAL CLINIC PC
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:HILLBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-273-0490
Mailing Address - Street 1:PO BOX 725
Mailing Address - Street 2:
Mailing Address - City:LOLO
Mailing Address - State:MT
Mailing Address - Zip Code:59847
Mailing Address - Country:US
Mailing Address - Phone:406-273-0490
Mailing Address - Fax:406-273-7969
Practice Address - Street 1:108 TYLER WAY
Practice Address - Street 2:
Practice Address - City:LOLO
Practice Address - State:MT
Practice Address - Zip Code:59847
Practice Address - Country:US
Practice Address - Phone:406-273-0490
Practice Address - Fax:406-273-7969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty