Provider Demographics
NPI:1720081201
Name:LIDAHL, TOM RICHARD (DMD)
Entity type:Individual
Prefix:
First Name:TOM
Middle Name:RICHARD
Last Name:LIDAHL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLENTYWOOD
Mailing Address - State:MT
Mailing Address - Zip Code:59254-1843
Mailing Address - Country:US
Mailing Address - Phone:406-765-2700
Mailing Address - Fax:406-765-1514
Practice Address - Street 1:223 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PLENTYWOOD
Practice Address - State:MT
Practice Address - Zip Code:59254-1843
Practice Address - Country:US
Practice Address - Phone:406-765-2700
Practice Address - Fax:406-765-1514
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT13271223G0001X
MND10463122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Not Answered122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT13274OtherBCBS PROVIDER NUMBER
MT5510244OtherCHIP PROVIDER NUMBER
ND991068OtherBCBS PROVIDER NUMBER
MT0116792Medicaid