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TOM RICHARD LIDAHL D.M.D.
General Practice >> Dentist >> Dental ProvidersRegistrant NPI Number: 1720081201
Individual Registrant: TOM RICHARD LIDAHL D.M.D.
Gender: M
Not Sole Proprietor
Gender: M
Not Sole Proprietor
Location and contact information for practice:
223 N MAIN ST PLENTYWOOD, MT 59254-1843 US
Tel: 406-765-2700 Fax: 406-765-1514
Tel: 406-765-2700 Fax: 406-765-1514
Contact information for business:
223 N MAIN ST PLENTYWOOD, MT 59254-1843 US
Tel: 406-765-2700 Fax: 406-765-1514
Tel: 406-765-2700 Fax: 406-765-1514
Registration Information:
NPI: 1720081201
Entity Type: Individual
Entity Type: Individual
Specialty information:
| Primary | Code | Category/Description | State | License Number |
|---|---|---|---|---|
| X | 1223G0001X | Dental Providers Dentist General Practice | MT | 1327 |
| X | 122300000X | Dental Providers Dentist | MN | D10463 |
Legacy codes, insurance codes and state license numbers:
| Issuer | Number | State | Type |
|---|---|---|---|
| CHIP PROVIDER NUMBER | 5510244 | MT | 01 |
| BCBS PROVIDER NUMBER | 991068 | ND | 01 |
| BCBS PROVIDER NUMBER | 13274 | MT | 01 |
| 0116792 | MT | 05 |
