Provider Demographics
NPI:1710105044
Name:MINTZ, GARY R (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:R
Last Name:MINTZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1171
Mailing Address - Street 2:
Mailing Address - City:GLENDIVE
Mailing Address - State:MT
Mailing Address - Zip Code:59330-1171
Mailing Address - Country:US
Mailing Address - Phone:406-377-2303
Mailing Address - Fax:406-377-3950
Practice Address - Street 1:218 W BELL ST
Practice Address - Street 2:SUITE 102
Practice Address - City:GLENDIVE
Practice Address - State:MT
Practice Address - Zip Code:59330-1644
Practice Address - Country:US
Practice Address - Phone:406-377-2303
Practice Address - Fax:406-377-3950
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT14931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1285851014OtherNPI JASON J ROAN