Healthcare Provider Details

I. General information

NPI: 1083191035
Provider Name (Legal Business Name): OWENS FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2018
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 S HWY 89
JACKSON WY
83001-8512
US

IV. Provider business mailing address

PO BOX 629
JACKSON WY
83001-0629
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-3848
  • Fax: 307-733-8978
Mailing address:
  • Phone: 307-733-3848
  • Fax: 307-733-8978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number128WY
License Number StateWY

VIII. Authorized Official

Name: DR. SUMMER CATHLIN OWENS
Title or Position: OWNER
Credential: DDS
Phone: 307-733-3848