Provider Demographics
NPI:1720081201
Name:LIDAHL, TOM RICHARD (DMD)
Entity type:Individual
Prefix:
First Name:TOM
Middle Name:RICHARD
Last Name:LIDAHL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLENTYWOOD
Mailing Address - State:MT
Mailing Address - Zip Code:59254-1843
Mailing Address - Country:US
Mailing Address - Phone:406-765-2700
Mailing Address - Fax:406-765-1514
Practice Address - Street 1:223 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PLENTYWOOD
Practice Address - State:MT
Practice Address - Zip Code:59254-1843
Practice Address - Country:US
Practice Address - Phone:406-765-2700
Practice Address - Fax:406-765-1514
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT13271223G0001X
MND10463122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT13274OtherBCBS PROVIDER NUMBER
MT5510244OtherCHIP PROVIDER NUMBER
ND991068OtherBCBS PROVIDER NUMBER
MT0116792Medicaid