Provider Demographics
NPI:1679519805
Name:BOTNER, MICHELLE LEIDENIX (OD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEIDENIX
Last Name:BOTNER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 CENTRAL AVE.
Mailing Address - Street 2:STE. B
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-2664
Mailing Address - Country:US
Mailing Address - Phone:406-860-2020
Mailing Address - Fax:406-862-2385
Practice Address - Street 1:346 CENTRAL AVE.
Practice Address - Street 2:STE. B
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-2664
Practice Address - Country:US
Practice Address - Phone:406-862-2020
Practice Address - Fax:406-862-2385
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT1562152W00000X
NDND 511152W00000X
MT1562152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60433Medicaid
MT1679519805Medicaid