Healthcare Provider Details

I. General information

NPI: 1174942122
Provider Name (Legal Business Name): BREANNA BARNES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 10/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1439 STILLWATER AVE STE 7
CHEYENNE WY
82009-7367
US

IV. Provider business mailing address

1439 STILLWATER AVE STE 7
CHEYENNE WY
82009-7367
US

V. Phone/Fax

Practice location:
  • Phone: 307-778-7100
  • Fax:
Mailing address:
  • Phone: 307-778-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number61240
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number61240
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number1507
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: