Healthcare Provider Details

I. General information

NPI: 1306190749
Provider Name (Legal Business Name): REBECCA E. CLOETTA D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2012
Last Update Date: 11/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 S HWY 89 SUITE 102
JACKSON WY
83002-1570
US

IV. Provider business mailing address

PO BOX 11570
JACKSON WY
83002-1570
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-4122
  • Fax: 307-733-4164
Mailing address:
  • Phone: 307-733-4122
  • Fax: 307-733-4164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1009
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: