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General NPI Number Information
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NPI Number | 1881557072
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Entity Type | Organization
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Legal Business Name | SOUTHERN WYOMING PERIODONTICS LLC
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Dates
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Enumeration Date | 12/04/2025
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Last Update Date | 12/04/2025
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Provider Practice Location Address
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Address Line | 7010 YELLOWTAIL RD STE 200
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City | CHEYENNE
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State | WY
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Zip | 82009-6113
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Country | US
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Telephone | 307-423-0325
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Fax | 307-241-5357
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Provider Business Mailing Address
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Address Line | 7010 YELLOWTAIL RD STE 200
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City | CHEYENNE
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State | WY
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Zip | 82009-6113
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Country | US
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Telephone | 307-423-0325
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Fax | 307-241-5357
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Authorized Official
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Title or Position | OWNER DOCTOR
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Name | DR. JESSICA ALLEN
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Credential | DMD, MSD
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Telephone | 307-423-0325
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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