Healthcare Provider Details

I. General information

NPI: 1649575465
Provider Name (Legal Business Name): BEAR RIVER DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2011
Last Update Date: 01/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 PARK RD
EVANSTON WY
82930-2613
US

IV. Provider business mailing address

50 PARK RD
EVANSTON WY
82930-2613
US

V. Phone/Fax

Practice location:
  • Phone: 307-789-5608
  • Fax: 307-789-4401
Mailing address:
  • Phone: 307-789-5608
  • Fax: 307-789-4401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1250
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1257
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1202
License Number StateWY
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1131
License Number StateWY

VIII. Authorized Official

Name: NATHAN R LESTER
Title or Position: OWNER
Credential: DMD
Phone: 307-789-5608