Provider Demographics
NPI:1689752255
Name:ABENTROTH, ALISSA D (MD)
Entity Type:Individual
Prefix:DR
First Name:ALISSA
Middle Name:D
Last Name:ABENTROTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 E BROADWAY ST STE 200
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-8049
Mailing Address - Country:US
Mailing Address - Phone:406-457-4180
Mailing Address - Fax:
Practice Address - Street 1:2525 E BROADWAY ST STE 200
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-8049
Practice Address - Country:US
Practice Address - Phone:406-457-4180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12802208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery