Healthcare Provider Details

I. General information

NPI: 1740776202
Provider Name (Legal Business Name): TETON ORAL AND MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 07/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 ALPINE LN STE 1D
JACKSON WY
83001
US

IV. Provider business mailing address

PO BOX 9339
JACKSON WY
83002-9339
US

V. Phone/Fax

Practice location:
  • Phone: 307-739-8611
  • Fax: 307-739-8613
Mailing address:
  • Phone: 307-739-8611
  • Fax: 307-739-8613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: BRIDGET ANNE MULLEN
Title or Position: OFFICE MANAGER
Credential: RN
Phone: 307-690-1513