Healthcare Provider Details

I. General information

NPI: 1306046651
Provider Name (Legal Business Name): CHEYENNE ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2007
Last Update Date: 07/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6238 YELLOWSTONE RD
CHEYENNE WY
82009-3432
US

IV. Provider business mailing address

6238 YELLOWSTONE RD
CHEYENNE WY
82009-3432
US

V. Phone/Fax

Practice location:
  • Phone: 307-635-6940
  • Fax: 307-635-2839
Mailing address:
  • Phone: 307-635-6940
  • Fax: 307-635-2839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. REX L. DOLAN
Title or Position: OWNER
Credential: D.D.S
Phone: 307-635-6940