Provider Demographics
NPI:1710523725
Name:BIG SKY ORAL & FACIAL SURGERY
Entity Type:Organization
Organization Name:BIG SKY ORAL & FACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:WALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:406-585-1120
Mailing Address - Street 1:1125 W KAGY BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-5879
Mailing Address - Country:US
Mailing Address - Phone:406-585-1120
Mailing Address - Fax:406-587-1988
Practice Address - Street 1:1125 W KAGY BLVD STE 201
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-5879
Practice Address - Country:US
Practice Address - Phone:406-585-1120
Practice Address - Fax:406-587-1988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty