Provider Demographics
NPI:1063664795
Name:BLUE TOOTH DENTAL INC.
Entity Type:Organization
Organization Name:BLUE TOOTH DENTAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HANCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-789-9034
Mailing Address - Street 1:545 CHEYENNE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-5323
Mailing Address - Country:US
Mailing Address - Phone:307-789-9034
Mailing Address - Fax:307-789-9065
Practice Address - Street 1:545 CHEYENNE DR
Practice Address - Street 2:SUITE C
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5323
Practice Address - Country:US
Practice Address - Phone:307-789-9034
Practice Address - Fax:307-789-9065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-13
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118464400Medicare PIN