Provider Demographics
NPI:1720115363
Name:MOEN, DONALD K (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:K
Last Name:MOEN
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 1:505 W MAIN STREET
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LEWISTOWN
Mailing Address - State:MT
Mailing Address - Zip Code:59457-0703
Mailing Address - Country:US
Mailing Address - Phone:406-538-2376
Mailing Address - Fax:406-538-2376
Practice Address - Street 1:505 W MAIN STREET
Practice Address - Street 2:SUITE 105
Practice Address - City:LEWISTOWN
Practice Address - State:MT
Practice Address - Zip Code:59457-0703
Practice Address - Country:US
Practice Address - Phone:406-538-2376
Practice Address - Fax:406-538-2376
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1600122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT110695Medicaid