MEDICARE: TETON ORAL & MAXILLOFACIAL SURGERY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
2	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164430971
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TETON ORAL & MAXILLOFACIAL SURGERY

Provider Business Mailing Address
First Line	:	PO BOX 9339
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83002-9339
Country	:	US
Telephone Number	:	307-739-8611
Fax Number	:	307-739-8613

Provider Business Practice Location Address
First Line	:	1160 ALPINE LANE
Second Line	:	#1D
City	:	JACKSON
State	:	WY
Zip	:	83002
Country	:	US
Telephone Number	:	307-739-8611
Fax Number	:	307-739-8613

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICHAEL STERN
Credential	:	DMD PHD
Telephone Number	:	307-739-8611

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	07/26/2018

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Directions to “TETON ORAL & MAXILLOFACIAL SURGERY ” Practice Location

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