Provider Demographics
NPI:1023130788
Name:CALDERWOOD, DEAN W
Entity type:Individual
Prefix:DR
First Name:DEAN
Middle Name:W
Last Name:CALDERWOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DEAN
Other - Middle Name:W
Other - Last Name:CALDERWOOD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:275 BAD ROCK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59912-9211
Mailing Address - Country:US
Mailing Address - Phone:406-892-3702
Mailing Address - Fax:
Practice Address - Street 1:125 NUCLEUS AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA FALLS
Practice Address - State:MT
Practice Address - Zip Code:59912-4010
Practice Address - Country:US
Practice Address - Phone:406-892-2104
Practice Address - Fax:406-892-1422
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT16071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1607OtherSTATE LICENSE NUMBER
MT0111293Medicaid