Healthcare Provider Details

I. General information

NPI: 1881557072
Provider Name (Legal Business Name): SOUTHERN WYOMING PERIODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7010 YELLOWTAIL RD STE 200
CHEYENNE WY
82009-6113
US

IV. Provider business mailing address

7010 YELLOWTAIL RD STE 200
CHEYENNE WY
82009-6113
US

V. Phone/Fax

Practice location:
  • Phone: 307-423-0325
  • Fax: 307-241-5357
Mailing address:
  • Phone: 307-423-0325
  • Fax: 307-241-5357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. JESSICA ALLEN
Title or Position: OWNER DOCTOR
Credential: DMD, MSD
Phone: 307-423-0325