Provider Demographics
NPI:1942483524
Name:MISSOULA PEDIATRIC DENTISTRY PC
Entity Type:Organization
Organization Name:MISSOULA PEDIATRIC DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:TIEDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-541-7334
Mailing Address - Street 1:1300 SOUTH RESERVE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801
Mailing Address - Country:US
Mailing Address - Phone:406-541-7334
Mailing Address - Fax:406-541-7338
Practice Address - Street 1:1300 SOUTH RESERVE ST
Practice Address - Street 2:SUITE B
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801
Practice Address - Country:US
Practice Address - Phone:406-541-7334
Practice Address - Fax:406-541-7338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT22291223G0001X
MTMT22121223G0001X
MTMT21511223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1558308221Medicaid
MT5512641OtherCHIPS