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General NPI Number Information
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NPI Number | 1881194280
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Entity Type | Organization
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Legal Business Name | 2ND STREET DENTAL, LLC
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Dates
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Enumeration Date | 02/13/2018
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Last Update Date | 02/13/2018
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Provider Practice Location Address
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Address Line | 2546 E 2ND ST STE 300
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City | CASPER
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State | WY
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Zip | 82609-2062
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Country | US
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Telephone | 307-337-3717
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Fax |
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Provider Business Mailing Address
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Address Line | 2546 E 2ND ST STE 300
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City | CASPER
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State | WY
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Zip | 82609-2062
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Country | US
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Telephone | 307-337-3717
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Fax |
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. MIRANDA ANN HAEFELE
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Credential | DDS
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Telephone | 307-337-3717
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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 | 1316
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License Number State | WY
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