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General NPI Number Information
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NPI Number | 1013289966
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Entity Type | Organization
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Legal Business Name | GILLETTE PEDIATRIC DENTISTRY LLC
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Dates
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Enumeration Date | 02/07/2012
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Last Update Date | 01/06/2017
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Provider Practice Location Address
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Address Line | 433 SHADOW RIDGE BLVD
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City | SHERIDAN
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State | WY
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Zip | 82801-9350
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Country | US
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Telephone | 307-670-8118
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Fax |
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Provider Business Mailing Address
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Address Line | 530 RUNNING W DRIVE SUITE 100
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City | GILLETTE
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State | WY
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Zip | 82718-2003
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Country | US
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Telephone | 307-670-8118
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Fax |
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Authorized Official
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Title or Position | PEDIATRIC DENTIST
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Name | DR. DAVID GLENN BAILEY
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Credential | D.D.S.
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Telephone | 307-670-8118
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 1271
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License Number State | WY
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