Healthcare Provider Details

I. General information

NPI: 1265848774
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2014
Last Update Date: 07/03/2014
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: 307-778-2824
Mailing address:
  • Phone: 307-778-7100
  • Fax: 307-778-2824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW C HENRY
Title or Position: OWNER
Credential: D.D.S.
Phone: 307-778-7100