Provider Demographics
NPI:1750507703
Name:GALLATIN VALLEY PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:GALLATIN VALLEY PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SAYRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-599-9086
Mailing Address - Street 1:115 W KAGY BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6027
Mailing Address - Country:US
Mailing Address - Phone:406-587-2327
Mailing Address - Fax:406-587-3338
Practice Address - Street 1:115 W KAGY BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6027
Practice Address - Country:US
Practice Address - Phone:406-587-2327
Practice Address - Fax:406-587-3338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT22121223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0033436Medicaid