Provider Demographics
NPI:1841203460
Name:WOOD, RICHARD S (DDS)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:S
Last Name:WOOD
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 1566
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-1566
Mailing Address - Country:US
Mailing Address - Phone:406-293-7541
Mailing Address - Fax:406-293-6510
Practice Address - Street 1:217 E 2ND ST
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-1566
Practice Address - Country:US
Practice Address - Phone:406-293-7541
Practice Address - Fax:406-293-6510
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT136344Medicaid
MT5510006OtherCHIPS