Provider Demographics
NPI:1407116338
Name:FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY MONTANA PC
Entity type:Organization
Organization Name:FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY MONTANA PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RF JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTZEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:406-549-6600
Mailing Address - Street 1:805 S RESERVE ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-2104
Mailing Address - Country:US
Mailing Address - Phone:406-549-6600
Mailing Address - Fax:406-549-1511
Practice Address - Street 1:805 S RESERVE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-2104
Practice Address - Country:US
Practice Address - Phone:406-549-6600
Practice Address - Fax:406-549-1511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-25
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
MT12580261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT60882OtherBLUE CROSS BLUE SHIELD
MT60882OtherBLUE CROSS BLUE SHIELD