Healthcare Provider Details

I. General information

NPI: 1689883589
Provider Name (Legal Business Name): DANE ST. JOHN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 04/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 SHERIDAN AVE
CODY WY
82414
US

IV. Provider business mailing address

707 SHERIDAN AVE
CODY WY
82414
US

V. Phone/Fax

Practice location:
  • Phone: 307-578-2500
  • Fax: 307-578-2492
Mailing address:
  • Phone: 307-578-2500
  • Fax: 307-578-2492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number27461
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9197A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: