Healthcare Provider Details

I. General information

NPI: 1710004569
Provider Name (Legal Business Name): WHISKEY MOUNTAIN DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 08/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 NORTH 1ST STREET
DUBOIS WY
82513
US

IV. Provider business mailing address

PO BOX 783
DUBOIS WY
82513-0783
US

V. Phone/Fax

Practice location:
  • Phone: 307-455-2029
  • Fax:
Mailing address:
  • Phone: 307-455-2229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MARIE DAY
Title or Position: OFFICE MANAGER DENTAL ASSISTANT
Credential:
Phone: 307-455-2229