Active NPI
Derek Charles Mettenbrink, DDS
- Pediatric Dentistry
- Missoula, MT
National Provider Identifier
1629636097
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Dentistry
- License
- 7535
- Practice address
- 3020 S Reserve St Ste D
Missoula, MT 59801-7652 - Phone
- (406) 541-7337
- NPI assigned
- May 31, 2019
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Dentistry | 1223P0221X | 7535 | NE | Primary |
| Pediatric Dentistry | 1223P0221X | DEN-DEN-LIC-19245 | MT |
Addresses
Primary practice location
3020 S Reserve St Ste D
Missoula, MT 59801-7652
Mailing address
4256 Diagon LN
Missoula, MT 59808-5306
Phone (308) 380-5938
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DEN-DEN-LIC-19245 | MT | MD | Pediatric Dentist |
| 7535 | NE | MD | Pediatric Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1559260800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1641513600000",
"number": "1629636097",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4256 DIAGON LN",
"city": "MISSOULA",
"state": "MT",
"postal_code": "598085306",
"telephone_number": "308-380-5938"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3020 S RESERVE ST STE D",
"city": "MISSOULA",
"state": "MT",
"postal_code": "598017652",
"telephone_number": "406-541-7337"
}
],
"practiceLocations": [],
"basic": {
"last_name": "METTENBRINK",
"first_name": "DEREK",
"middle_name": "CHARLES",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2019-05-31",
"last_updated": "2022-01-07",
"certification_date": "2022-01-07",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "NE",
"license": "7535",
"primary": true
},
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "MT",
"license": "DEN-DEN-LIC-19245",
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Missoula, MT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 7, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.