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General NPI Number Information
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NPI Number | 1649575465
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Entity Type | Organization
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Legal Business Name | BEAR RIVER DENTAL
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Dates
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Enumeration Date | 01/26/2011
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Last Update Date | 01/26/2011
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Provider Practice Location Address
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Address Line | 50 PARK RD
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City | EVANSTON
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State | WY
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Zip | 82930-2613
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Country | US
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Telephone | 307-789-5608
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Fax | 307-789-4401
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Provider Business Mailing Address
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Address Line | 50 PARK RD
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City | EVANSTON
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State | WY
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Zip | 82930-2613
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Country | US
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Telephone | 307-789-5608
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Fax | 307-789-4401
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Authorized Official
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Title or Position | OWNER
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Name | NATHAN R LESTER
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Credential | DMD
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Telephone | 307-789-5608
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 1250
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License Number State | WY
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 1257
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License Number State | WY
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Taxonomy #3
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 1202
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License Number State | WY
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Taxonomy #4
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 1131
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License Number State | WY
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