Provider Demographics
NPI:1457430118
Name:FIRST IMPRESSIONS DENTURE CLINIC LLC
Entity Type:Organization
Organization Name:FIRST IMPRESSIONS DENTURE CLINIC LLC
Other - Org Name:LIMITED LIABILITY COMPANY
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTURIST AND LLC MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:CASTEEL
Authorized Official - Suffix:
Authorized Official - Credentials:LD
Authorized Official - Phone:406-216-4746
Mailing Address - Street 1:PO BOX 165
Mailing Address - Street 2:
Mailing Address - City:BLACK EAGLE
Mailing Address - State:MT
Mailing Address - Zip Code:59414-0165
Mailing Address - Country:US
Mailing Address - Phone:406-216-4746
Mailing Address - Fax:406-216-4747
Practice Address - Street 1:215 SMELTER AVE NE
Practice Address - Street 2:STE #3
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59404-1937
Practice Address - Country:US
Practice Address - Phone:406-216-4746
Practice Address - Fax:406-216-4747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000030314OtherBCBS
MT5512471OtherCHIP
MT0150178Medicaid