Healthcare Provider Details

I. General information

NPI: 1750629333
Provider Name (Legal Business Name): CLIFFORD OLGUIN DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2013
Last Update Date: 01/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 MEADOW ST # 11
LYMAN WY
82937-9008
US

IV. Provider business mailing address

37 MEADOW ST # 11
LYMAN WY
82937-9008
US

V. Phone/Fax

Practice location:
  • Phone: 307-786-2300
  • Fax: 307-786-2345
Mailing address:
  • Phone: 307-786-2300
  • Fax: 307-786-2345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1064
License Number StateWY

VIII. Authorized Official

Name: DR. ZANNA LEE CLIFFORD-OLGUIN
Title or Position: DENTSIT
Credential: DDS
Phone: 307-786-2300