Provider Demographics
NPI:1063563443
Name:POTTHOFF, RONALD B (DDS)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:B
Last Name:POTTHOFF
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 COMMONS LOOP STE A
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-1912
Mailing Address - Country:US
Mailing Address - Phone:406-755-5280
Mailing Address - Fax:406-752-7679
Practice Address - Street 1:195 COMMONS LOOP STE A
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-1912
Practice Address - Country:US
Practice Address - Phone:406-755-5280
Practice Address - Fax:406-752-7679
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT19421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT40794OtherBLUE CROSS OF MT
MT5510941OtherCHIPS
MT111282Medicaid