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General NPI Number Information
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NPI Number | 1477376929
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Entity Type | Organization
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Legal Business Name | MOUNTAIN DENTAL DUBOIS - AD LLC
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Dates
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Enumeration Date | 11/04/2024
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Last Update Date | 11/04/2024
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Provider Practice Location Address
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Address Line | 104 N. 1ST STREET
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City | DUBOIS
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State | WY
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Zip | 82513
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Country | US
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Telephone | 307-455-2229
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 777
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City | DUBOIS
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State | WY
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Zip | 82513-0777
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Country | US
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Telephone | 307-455-2229
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE ADVISOR
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Name | MRS. TAYLOR ASHCRAFT
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Credential |
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Telephone | 208-716-5669
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 |
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