Provider Demographics
NPI:1134333719
Name:BRISENDINE, FRANK (LD)
Entity type:Individual
Prefix:
First Name:FRANK
Middle Name:
Last Name:BRISENDINE
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 728
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:MT
Mailing Address - Zip Code:59922-0728
Mailing Address - Country:US
Mailing Address - Phone:406-857-3711
Mailing Address - Fax:406-857-3712
Practice Address - Street 1:LAKESIDE DENTURE STUDIO
Practice Address - Street 2:6420 HWY 93 SOUTH
Practice Address - City:LAKESIDE
Practice Address - State:MT
Practice Address - Zip Code:59922-0728
Practice Address - Country:US
Practice Address - Phone:406-857-3711
Practice Address - Fax:406-857-3712
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0150144Medicaid