Healthcare Provider Details

I. General information

NPI: 1194248625
Provider Name (Legal Business Name): THALES CHRISTIAN HASKELL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 EAGLE VIEW DR
BUFFALO WY
82834-1417
US

IV. Provider business mailing address

3090 TALON DR
CASPER WY
82604-3279
US

V. Phone/Fax

Practice location:
  • Phone: 307-684-0119
  • Fax: 307-684-0120
Mailing address:
  • Phone: 307-237-1801
  • Fax: 307-237-3686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1475
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: