Healthcare Provider Details

I. General information

NPI: 1033870779
Provider Name (Legal Business Name): PINEDALE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2022
Last Update Date: 01/05/2022
Certification Date: 01/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 FREMONT LAKE RD
PINEDALE WY
82941-5213
US

IV. Provider business mailing address

PO BOX 1190
PINEDALE WY
82941-1190
US

V. Phone/Fax

Practice location:
  • Phone: 307-367-3700
  • Fax: 307-312-2848
Mailing address:
  • Phone: 307-367-3700
  • Fax: 307-312-2848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ALISON PETERSEN
Title or Position: RECEPTIONIST
Credential:
Phone: 307-367-3700