Provider Demographics
NPI:1487905931
Name:BRISENDINE, CARL JUSTIN (LD)
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:JUSTIN
Last Name:BRISENDINE
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 SUNSET PLZ
Mailing Address - Street 2:SUITE C
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3608
Mailing Address - Country:US
Mailing Address - Phone:406-752-3733
Mailing Address - Fax:406-752-3734
Practice Address - Street 1:6 SUNSET PLZ
Practice Address - Street 2:SUITE C
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3608
Practice Address - Country:US
Practice Address - Phone:406-752-3733
Practice Address - Fax:406-752-3734
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4206122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist