Provider Demographics
NPI:1902455074
Name:EPIPHANY DERMATOLOGY OF MONTANA, PLLC
Entity Type:Organization
Organization Name:EPIPHANY DERMATOLOGY OF MONTANA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/MANAGING EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:GHEORGHE
Authorized Official - Middle Name:
Authorized Official - Last Name:PUSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-960-5760
Mailing Address - Street 1:7300 RANCH RD. 2222, BLDG 1, STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730
Mailing Address - Country:US
Mailing Address - Phone:512-628-0465
Mailing Address - Fax:512-233-2711
Practice Address - Street 1:24 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-9334
Practice Address - Country:US
Practice Address - Phone:406-723-7272
Practice Address - Fax:406-723-3328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-10
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty