Provider Demographics
NPI:1912921594
Name:KLISE, TERRY (DDS)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:
Last Name:KLISE
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 1:2603 DEER CANYON CT
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-8638
Mailing Address - Country:US
Mailing Address - Phone:406-529-2612
Mailing Address - Fax:406-721-1126
Practice Address - Street 1:2603 DEER CANYON CT
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-8638
Practice Address - Country:US
Practice Address - Phone:406-529-2612
Practice Address - Fax:406-721-1126
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT22291223D0004X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDental Anesthesiology
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200317590Medicaid