Healthcare Provider Details

I. General information

NPI: 1669916334
Provider Name (Legal Business Name): BRACES U WYOMING PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2016
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 YELLOWTAIL RD STE 100
CHEYENNE WY
82009-6102
US

IV. Provider business mailing address

4360 BOARDWALK DR STE 200
FORT COLLINS CO
80525-5940
US

V. Phone/Fax

Practice location:
  • Phone: 307-632-2480
  • Fax: 307-635-9218
Mailing address:
  • Phone: 970-226-5505
  • Fax: 970-226-8669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number1297
License Number StateWY

VIII. Authorized Official

Name: CORY FAUST COOMBS
Title or Position: PRESIDENT
Credential: DMD
Phone: 970-226-5505