Provider Demographics
NPI:1033699533
Name:OAK HAVEN DENTAL
Entity Type:Organization
Organization Name:OAK HAVEN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRONT OFFICE
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:R
Authorized Official - Last Name:JAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-332-3181
Mailing Address - Street 1:8125 STATE HIGHWAY 789
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-2926
Mailing Address - Country:US
Mailing Address - Phone:307-332-3181
Mailing Address - Fax:
Practice Address - Street 1:8125 STATE HIGHWAY 789
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-2926
Practice Address - Country:US
Practice Address - Phone:307-332-3181
Practice Address - Fax:307-332-3484
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OAK HAVEN DENTAL LANDER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1223G0001X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY=========Medicaid