Provider Demographics
NPI:1871701854
Name:GIVIDEN, STACEY LAURA (DDS)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:LAURA
Last Name:GIVIDEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:STACEY
Other - Middle Name:LAURA
Other - Last Name:SIMMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:710 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2134
Mailing Address - Country:US
Mailing Address - Phone:406-375-1192
Mailing Address - Fax:406-375-1193
Practice Address - Street 1:710 N 1ST ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2134
Practice Address - Country:US
Practice Address - Phone:406-375-1192
Practice Address - Fax:406-375-1193
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT21411223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice