Provider Demographics
NPI:1376638304
Name:POLLOCK, SAM R (DDS)
Entity type:Individual
Prefix:DR
First Name:SAM
Middle Name:R
Last Name:POLLOCK
Suffix:
Gender:M
Credentials:DDS
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 1025
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MT
Mailing Address - Zip Code:59044
Mailing Address - Country:US
Mailing Address - Phone:406-628-6716
Mailing Address - Fax:406-628-6373
Practice Address - Street 1:15 MONTANA AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MT
Practice Address - Zip Code:59044
Practice Address - Country:US
Practice Address - Phone:406-628-6716
Practice Address - Fax:406-628-6373
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2051122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT20514OtherBLUECROSS
MT5512369OtherCHIP
MT0120105Medicaid
MT5512369OtherCHIP