| NPI | 1235238718 |
|---|---|
| Doing Business As | BLACKTAIL DENTAL |
| Doing Business As | BLACKTAIL MEDICAL CLINIC |
| Entity Type | Organization |
| Authorized Contact | KAYLA MEDINA Credentialing Coordinator 406-723-4075 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) |
| Additional Taxonomies | 261Q00000X Clinic/Center |
| 261Q00000X Clinic/Center | |
| 261QD0000X Clinic/Center, Dental | |
| 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) | |
| Enumeration Date | 2006-09-21 |
| Last Update Date | 2025-08-25 |