Provider Demographics
NPI:1164147666
Name:CASPER MOUNTAIN DENTAL DBA ADVANCED FAMILY DENTAL
Entity Type:Organization
Organization Name:CASPER MOUNTAIN DENTAL DBA ADVANCED FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-259-0058
Mailing Address - Street 1:1431 S. BEVERLY STREET
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609
Mailing Address - Country:US
Mailing Address - Phone:307-265-5334
Mailing Address - Fax:307-265-5336
Practice Address - Street 1:1431 S. BEVERLY STREET
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609
Practice Address - Country:US
Practice Address - Phone:307-265-5334
Practice Address - Fax:307-265-5336
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CASPER MOUNTAIN DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY131751200Medicaid