Provider Demographics
NPI:1033574827
Name:KINCHELOE & TONSO FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:KINCHELOE & TONSO FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:BURNS
Authorized Official - Last Name:KINCHELOE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-638-8520
Mailing Address - Street 1:6244 YELLOWSTONE RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-3432
Mailing Address - Country:US
Mailing Address - Phone:307-638-8520
Mailing Address - Fax:307-638-6857
Practice Address - Street 1:6244 YELLOWSTONE RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-3432
Practice Address - Country:US
Practice Address - Phone:307-638-8520
Practice Address - Fax:307-638-6857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY116897500Medicaid