Healthcare Provider Details

I. General information

NPI: 1356817118
Provider Name (Legal Business Name): GREYBULL DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2018
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

337 GREYBULL AVE
GREYBULL WY
82426
US

IV. Provider business mailing address

240 E. MAIN ST.
LOVELL WY
82431
US

V. Phone/Fax

Practice location:
  • Phone: 307-548-7654
  • Fax:
Mailing address:
  • Phone: 307-548-7654
  • 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: DR. LANCE ELDON ANDERSON
Title or Position: DENTIST/OWNER
Credential: DMD
Phone: 307-548-7654