Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | 4206 | MT |
NPI | 1487905931 |
---|---|
Provider Name | Mr. Carl Justin Brisendine |
First Address | Kalispell, MT 59901-3608 |
Second Address | Kalispell, MT 59901-3608 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/09/2012 |
Last Update Date | 10/06/2013 |