Provider Demographics
NPI:1821379009
Name:WESTERN MONTANA FAMILY DENTISTRY
Entity Type:Organization
Organization Name:WESTERN MONTANA FAMILY DENTISTRY
Other - Org Name:BAGNELL FAMILY DENTISTRY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:BAGNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:406-676-8880
Mailing Address - Street 1:63355 US HIGHWAY 93
Mailing Address - Street 2:
Mailing Address - City:RONAN
Mailing Address - State:MT
Mailing Address - Zip Code:59864-2702
Mailing Address - Country:US
Mailing Address - Phone:406-676-8880
Mailing Address - Fax:406-676-8881
Practice Address - Street 1:63355 US HIGHWAY 93
Practice Address - Street 2:
Practice Address - City:RONAN
Practice Address - State:MT
Practice Address - Zip Code:59864-2702
Practice Address - Country:US
Practice Address - Phone:406-676-8880
Practice Address - Fax:406-676-8881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-01
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1951122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty