Provider Demographics
NPI:1912557653
Name:KILGORE, SUMMOR (RDH, OMT)
Entity Type:Individual
Prefix:MISS
First Name:SUMMOR
Middle Name:
Last Name:KILGORE
Suffix:
Gender:F
Credentials:RDH, OMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1099 COWBOY WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59912-9068
Mailing Address - Country:US
Mailing Address - Phone:406-291-0634
Mailing Address - Fax:
Practice Address - Street 1:1099 COWBOY WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA FALLS
Practice Address - State:MT
Practice Address - Zip Code:59912-9068
Practice Address - Country:US
Practice Address - Phone:406-291-0634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-15
Last Update Date:2019-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTDEN-RDH-1207124Q00000X, 125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes125J00000XDental ProvidersDental TherapistGroup - Single Specialty
No124Q00000XDental ProvidersDental Hygienist