Provider Demographics
NPI:1003069865
Name:WYOMING COSMETIC AND FAMILY DENTAL
Entity Type:Organization
Organization Name:WYOMING COSMETIC AND FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:N
Authorized Official - Last Name:WHITING
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:307-635-2419
Mailing Address - Street 1:4620 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4963
Mailing Address - Country:US
Mailing Address - Phone:307-635-2419
Mailing Address - Fax:307-772-3443
Practice Address - Street 1:4620 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4963
Practice Address - Country:US
Practice Address - Phone:307-635-2419
Practice Address - Fax:307-772-3443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-24
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1199261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1265421077OtherINDIVIDUAL NPI