Healthcare Provider Details

I. General information

NPI: 1033699533
Provider Name (Legal Business Name): OAK HAVEN DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8125 STATE HIGHWAY 789
LANDER WY
82520-2926
US

IV. Provider business mailing address

8125 STATE HIGHWAY 789
LANDER WY
82520-2926
US

V. Phone/Fax

Practice location:
  • Phone: 307-332-3181
  • Fax: 307-332-3484
Mailing address:
  • Phone: 307-332-3181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. CHARLOTTE R JAY
Title or Position: FRONT OFFICE
Credential:
Phone: 307-332-3181