Healthcare Provider Details

I. General information

NPI: 1568440519
Provider Name (Legal Business Name): MARY KAY KRIVY D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7010 YELLOWTAIL RD. SUITE 100
CHEYENNE WY
82009-7368
US

IV. Provider business mailing address

7010 YELLOWTAIL RD. SUITE 100
CHEYENNE WY
82009-7368
US

V. Phone/Fax

Practice location:
  • Phone: 307-632-6597
  • Fax: 307-632-2170
Mailing address:
  • Phone: 307-632-6597
  • Fax: 307-632-2170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number963
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: