Basic Information
| Provider Information | |||||||||
| NPI: | 1003038290 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HARDIN DENTAL CLINIC, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 433 | ||||||||
| Address2: | |||||||||
| City: | HARDIN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 590340433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066653300 | ||||||||
| FaxNumber: | 4066654290 | ||||||||
| Practice Location | |||||||||
| Address1: | 339 3RD ST W | ||||||||
| Address2: | |||||||||
| City: | HARDIN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 590341703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4066653300 | ||||||||
| FaxNumber: | 4066654290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 01/08/2009 | ||||||||
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| AuthorizedOfficialLastName: | MURPHY | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4066653300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 1717 | MT | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 115661 | 05 | MT | MEDICAID | 4 | 01 | MT | BLUE CROSS BLUE SHIELD | OTHER | 5510312 | 01 | MT | CHIP | OTHER | 857200 | 01 | MT | UNITED CONCORDIA | OTHER |