MEDICARE: SOUTHERN WYOMING PERIODONTICS LLC

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	1223P0300X	Periodontics

General Provider Information

NPI Number	:	1881557072
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN WYOMING PERIODONTICS LLC

Provider Business Mailing Address
First Line	:	7010 YELLOWTAIL RD STE 200
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82009-6113
Country	:	US
Telephone Number	:	307-423-0325
Fax Number	:	307-241-5357

Provider Business Practice Location Address
First Line	:	7010 YELLOWTAIL RD STE 200
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82009-6113
Country	:	US
Telephone Number	:	307-423-0325
Fax Number	:	307-241-5357

Authorized Official
Title or Position	:	OWNER DOCTOR
Name	:	DR. JESSICA ALLEN
Credential	:	DMD, MSD
Telephone Number	:	307-423-0325

Provider Enumeration Date	:	12/04/2025
Last Update Date	:	12/04/2025

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