Provider Demographics
NPI:1033870779
Name:PINEDALE DENTAL
Entity Type:Organization
Organization Name:PINEDALE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-367-3700
Mailing Address - Street 1:PO BOX 1190
Mailing Address - Street 2:
Mailing Address - City:PINEDALE
Mailing Address - State:WY
Mailing Address - Zip Code:82941-1190
Mailing Address - Country:US
Mailing Address - Phone:307-367-3700
Mailing Address - Fax:307-312-2848
Practice Address - Street 1:33 FREMONT LAKE RD
Practice Address - Street 2:
Practice Address - City:PINEDALE
Practice Address - State:WY
Practice Address - Zip Code:82941-5213
Practice Address - Country:US
Practice Address - Phone:307-367-3700
Practice Address - Fax:307-312-2848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY207753100Medicaid
WY113694100Medicaid