Provider Demographics
NPI:1992355929
Name:GALLATIN VALLEY MAXILLOFACIAL & AESTHETIC SURGERY
Entity type:Organization
Organization Name:GALLATIN VALLEY MAXILLOFACIAL & AESTHETIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHISDAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:406-587-0767
Mailing Address - Street 1:1994 STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-0655
Mailing Address - Country:US
Mailing Address - Phone:406-587-0767
Mailing Address - Fax:406-587-2120
Practice Address - Street 1:1994 STADIUM DR
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-0655
Practice Address - Country:US
Practice Address - Phone:406-587-0767
Practice Address - Fax:406-587-2120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1689745804OtherNPI
MT1457573727OtherNPI
1336301266OtherNPI