Healthcare Provider Details

I. General information

NPI: 1780745190
Provider Name (Legal Business Name): FELLER AND FELLER ORTHODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 03/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 CASCADE DR
ROCK SPRINGS WY
82901-5652
US

IV. Provider business mailing address

2405 CASCADE DR
ROCK SPRINGS WY
82901-5652
US

V. Phone/Fax

Practice location:
  • Phone: 307-362-8842
  • Fax:
Mailing address:
  • Phone: 307-362-8842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1158
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number743
License Number StateWY

VIII. Authorized Official

Name: DR. PARLEY JACK FELLER
Title or Position: OWNER
Credential: DDS, MS
Phone: 307-362-8842