MEDICARE: HOLWEGNER ORTHODONTICS, 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	1285	WY

General Provider Information

NPI Number	:	1922420009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLWEGNER ORTHODONTICS, LLC

Provider Business Mailing Address
First Line	:	7010 YELLOWTAIL RD
Second Line	:	SUITE 200
City	:	CHEYENNE
State	:	WY
Zip	:	82009-6113
Country	:	US
Telephone Number	:	307-638-8958
Fax Number	:

Provider Business Practice Location Address
First Line	:	7010 YELLOWTAIL RD
Second Line	:	SUITE 200
City	:	CHEYENNE
State	:	WY
Zip	:	82009-6113
Country	:	US
Telephone Number	:	307-638-8958
Fax Number	:

Authorized Official
Title or Position	:	ORTHODONTIST
Name	:	DR. CALLISTA MARIE HOLWEGNER
Credential	:	D.D.S., M.S.
Telephone Number	:	307-638-8958

Provider Enumeration Date	:	01/09/2014
Last Update Date	:	01/09/2014

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