Provider Demographics
NPI:1861614182
Name:CONNIE L SMALL, DDS, PLLC
Entity type:Organization
Organization Name:CONNIE L SMALL, DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:406-755-4127
Mailing Address - Street 1:673 1ST AVENUE WEST N
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3607
Mailing Address - Country:US
Mailing Address - Phone:406-755-4127
Mailing Address - Fax:
Practice Address - Street 1:673 1ST AVENUE WEST N
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3607
Practice Address - Country:US
Practice Address - Phone:406-755-4127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT17581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0115124Medicaid
MT112115Medicaid