Healthcare Provider Details

I. General information

NPI: 1427421676
Provider Name (Legal Business Name): CHEYENNE FACIAL IMAGING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2015
Last Update Date: 11/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 AIRPORT PKWY STE 210
CHEYENNE WY
82001-1541
US

IV. Provider business mailing address

1401 AIRPORT PKWY STE 210
CHEYENNE WY
82001-1541
US

V. Phone/Fax

Practice location:
  • Phone: 307-316-4101
  • Fax: 307-224-1089
Mailing address:
  • Phone: 307-316-4101
  • Fax: 307-224-1089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number999
License Number StateWY

VIII. Authorized Official

Name: JASON L. BIRD
Title or Position: ORTHODONTIST
Credential: DDS
Phone: 307-316-4101