Provider Demographics
NPI: | 1861818668 |
---|---|
Name: | PEDIATRIC DENTISTRY PC |
Entity Type: | Organization |
Organization Name: | PEDIATRIC DENTISTRY PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | DENTIST |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | KEVIN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | RENCHER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 406-449-0189 |
Mailing Address - Street 1: | 3116 SADDLE DR |
Mailing Address - Street 2: | SUITE 1 |
Mailing Address - City: | HELENA |
Mailing Address - State: | MT |
Mailing Address - Zip Code: | 59601-8645 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 406-449-0189 |
Mailing Address - Fax: | 406-449-7237 |
Practice Address - Street 1: | 3116 SADDLE DR |
Practice Address - Street 2: | SUITE 1 |
Practice Address - City: | HELENA |
Practice Address - State: | MT |
Practice Address - Zip Code: | 59601-8645 |
Practice Address - Country: | US |
Practice Address - Phone: | 406-449-0189 |
Practice Address - Fax: | 406-449-7237 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2014-03-17 |
Last Update Date: | 2014-03-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MT | 2145 | 1223P0221X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223P0221X | Dental Providers | Dentist | Pediatric Dentistry | Group - Single Specialty |