Healthcare Provider Details

I. General information

NPI: 1457631558
Provider Name (Legal Business Name): EAGLE SUMMIT DENTAL CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2011
Last Update Date: 08/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 EAGLE VIEW DR
BUFFALO WY
82834-1422
US

IV. Provider business mailing address

1001 EAGLE VIEW DR
BUFFALO WY
82834-1422
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MONICA BURRIDGE
Title or Position: OFFICE MANAGER
Credential:
Phone: 307-684-0119