Healthcare Provider Details

I. General information

NPI: 1386856227
Provider Name (Legal Business Name): ACCESS DENTAL CARE CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 E 19TH ST
CHEYENNE WI
82001
US

IV. Provider business mailing address

405 E 19TH ST
CHEYENNE WI
82001
US

V. Phone/Fax

Practice location:
  • Phone: 307-632-6665
  • Fax: 307-637-6733
Mailing address:
  • Phone: 307-632-6665
  • Fax: 307-637-6733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number939
License Number StateWY

VIII. Authorized Official

Name: JOHN B LUDDINGTON
Title or Position: DENTIST
Credential: DDS
Phone: 307-632-6665