Healthcare Provider Details

I. General information

NPI: 1194205401
Provider Name (Legal Business Name): WYOMING COSMETIC AND FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4620 GRANDVIEW AVE SUITE #101
CHEYENNE WY
82009
US

IV. Provider business mailing address

4620 GRANDVIEW AVE SUITE 101
CHEYENNE WY
82009
US

V. Phone/Fax

Practice location:
  • Phone: 307-635-2419
  • Fax: 307-772-3443
Mailing address:
  • Phone: 307-635-2419
  • Fax: 307-772-3443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number1490
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1199
License Number StateWY

VIII. Authorized Official

Name: JASON WHITING
Title or Position: OWNER
Credential: DMD
Phone: 307-635-2419