Provider Demographics
NPI:1073973780
Name:JENNIFER DOSER DMD PC
Entity Type:Organization
Organization Name:JENNIFER DOSER DMD PC
Other - Org Name:GRAND AVENUE DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:DOSER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:307-742-0722
Mailing Address - Street 1:303 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-3914
Mailing Address - Country:US
Mailing Address - Phone:307-742-0722
Mailing Address - Fax:307-742-0727
Practice Address - Street 1:303 S 8TH ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-3914
Practice Address - Country:US
Practice Address - Phone:307-742-0722
Practice Address - Fax:307-742-0727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-24
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1255122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY129817800Medicaid
WY7527010001Medicare NSC