Healthcare Provider Details

I. General information

NPI: 1679952865
Provider Name (Legal Business Name): DENISE R PRUGH DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2015
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 N WALSH DR
CASPER WY
82609-1911
US

IV. Provider business mailing address

295 N WALSH DR
CASPER WY
82609-1911
US

V. Phone/Fax

Practice location:
  • Phone: 307-265-7878
  • Fax: 307-268-4953
Mailing address:
  • Phone: 307-265-7878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DENISE ROBIN PRUGH
Title or Position: OWNER
Credential: DDS
Phone: 307-265-7878