MEDICARE: DR. ERIC ANTHONY DZIARDZIEL D.D.S.

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	122300000X	Dentist	967	WY

General Provider Information

NPI Number	:	1225016272
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC ANTHONY DZIARDZIEL D.D.S.

Provider Business Mailing Address
First Line	:	2029 BLUEGRASS CIR
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82009-7368
Country	:	US
Telephone Number	:	307-632-6597
Fax Number	:	307-632-2170

Provider Business Practice Location Address
First Line	:	2029 BLUEGRASS CIR
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82009-7368
Country	:	US
Telephone Number	:	307-632-6597
Fax Number	:	307-632-2170

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2006
Last Update Date	:	07/08/2007

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