Provider Demographics
NPI:1700522398
Name:ROUNDUP FAMILY DENTISTRY
Entity Type:Organization
Organization Name:ROUNDUP FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:DAIGREPONT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:406-323-1234
Mailing Address - Street 1:239 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROUNDUP
Mailing Address - State:MT
Mailing Address - Zip Code:59072-2735
Mailing Address - Country:US
Mailing Address - Phone:406-323-1234
Mailing Address - Fax:
Practice Address - Street 1:239 MAIN ST
Practice Address - Street 2:
Practice Address - City:ROUNDUP
Practice Address - State:MT
Practice Address - Zip Code:59072-2735
Practice Address - Country:US
Practice Address - Phone:406-323-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-07
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT146801068Medicaid