Provider Demographics
NPI:1891830360
Name:GLACIER DENTAL GROUP, PC
Entity Type:Organization
Organization Name:GLACIER DENTAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DUSTY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-752-8081
Mailing Address - Street 1:795 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3699
Mailing Address - Country:US
Mailing Address - Phone:406-752-8081
Mailing Address - Fax:406-752-8083
Practice Address - Street 1:795 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3699
Practice Address - Country:US
Practice Address - Phone:406-752-8081
Practice Address - Fax:406-752-8083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT21951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0113696Medicaid
MT5512964OtherBLUE CHIP