Healthcare Provider Details

I. General information

NPI: 1467561167
Provider Name (Legal Business Name): BOZEMAN TRAIL ORTHODONTICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

932 SOUTH DAVID ST
CASPER WY
82601
US

IV. Provider business mailing address

932 SOUTH DAVID ST
CASPER WY
82601
US

V. Phone/Fax

Practice location:
  • Phone: 307-237-8419
  • Fax: 307-234-4912
Mailing address:
  • Phone: 307-237-8419
  • Fax: 307-234-4912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number546
License Number StateWY

VIII. Authorized Official

Name: DR. JAMES LEWIS WETZEL JR.
Title or Position: PRESIDENT
Credential: DDS
Phone: 307-237-8419