Healthcare Provider Details

I. General information

NPI: 1255725297
Provider Name (Legal Business Name): HARRELL DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 03/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 W CARLSON ST
CHEYENNE WY
82009-4044
US

IV. Provider business mailing address

121 W CARLSON ST
CHEYENNE WY
82009-4044
US

V. Phone/Fax

Practice location:
  • Phone: 307-635-1197
  • Fax:
Mailing address:
  • Phone: 307-635-1197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number1355
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number1173
License Number StateWY

VIII. Authorized Official

Name: DR. BENJAMIN J HARRELL
Title or Position: DENTIST
Credential: DDS, MBA
Phone: 307-635-1197