Provider Demographics
NPI:1679911044
Name:NORTHWEST DENTURE CENTER
Entity Type:Organization
Organization Name:NORTHWEST DENTURE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MACPHERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED DENTURIST
Authorized Official - Phone:406-542-0609
Mailing Address - Street 1:2021 S HIGGINS AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6762
Mailing Address - Country:US
Mailing Address - Phone:406-542-0609
Mailing Address - Fax:406-721-7617
Practice Address - Street 1:2021 S HIGGINS AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6762
Practice Address - Country:US
Practice Address - Phone:406-542-0609
Practice Address - Fax:406-721-7617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTDTR MT 18292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1215088166OtherNPI TYPE 1