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General NPI Number Information
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NPI Number | 1033699533
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Entity Type | Organization
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Legal Business Name | OAK HAVEN DENTAL
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Dates
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Enumeration Date | 08/15/2018
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Last Update Date | 08/15/2018
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Provider Practice Location Address
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Address Line | 8125 STATE HIGHWAY 789
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City | LANDER
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State | WY
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Zip | 82520-2926
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Country | US
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Telephone | 307-332-3181
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Fax | 307-332-3484
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Provider Business Mailing Address
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Address Line | 8125 STATE HIGHWAY 789
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City | LANDER
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State | WY
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Zip | 82520-2926
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Country | US
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Telephone | 307-332-3181
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Fax |
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Authorized Official
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Title or Position | FRONT OFFICE
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Name | MRS. CHARLOTTE R JAY
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Credential |
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Telephone | 307-332-3181
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State | WY
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