Provider Demographics
NPI:1982857892
Name:DEER CREEK DENTAL
Entity Type:Organization
Organization Name:DEER CREEK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATION PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:TYSON
Authorized Official - Middle Name:C
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:406-535-6317
Mailing Address - Street 1:310 WENDELL AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LEWISTOWN
Mailing Address - State:MT
Mailing Address - Zip Code:59457-2267
Mailing Address - Country:US
Mailing Address - Phone:406-535-6317
Mailing Address - Fax:
Practice Address - Street 1:310 WENDELL AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:LEWISTOWN
Practice Address - State:MT
Practice Address - Zip Code:59457-2267
Practice Address - Country:US
Practice Address - Phone:406-535-6317
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2310122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty