Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0004X | Dentist Anesthesiologist | 2229 | MT |
N | 1223G0001X | General Practice | 2229 | MT |
N | 213EG0000X | General Practice | 2229 | MT |
NPI | 1912921594 |
---|---|
Provider Name | Dr. Terry Klise |
First Address | Missoula, MT 59808-8638 |
Second Address | Missoula, MT 59808-8638 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/07/2006 |
Last Update Date | 28/07/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200317590 | (05) | IN |