Healthcare Provider Details

I. General information

NPI: 1922420009
Provider Name (Legal Business Name): HOLWEGNER ORTHODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2014
Last Update Date: 01/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7010 YELLOWTAIL RD SUITE 200
CHEYENNE WY
82009-6113
US

IV. Provider business mailing address

7010 YELLOWTAIL RD SUITE 200
CHEYENNE WY
82009-6113
US

V. Phone/Fax

Practice location:
  • Phone: 307-638-8958
  • Fax:
Mailing address:
  • Phone: 307-638-8958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1285
License Number StateWY

VIII. Authorized Official

Name: DR. CALLISTA MARIE HOLWEGNER
Title or Position: ORTHODONTIST
Credential: D.D.S., M.S.
Phone: 307-638-8958