Provider Demographics
NPI:1164430971
Name:TETON ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:TETON ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:STERN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD PHD
Authorized Official - Phone:307-739-8611
Mailing Address - Street 1:PO BOX 9339
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-9339
Mailing Address - Country:US
Mailing Address - Phone:307-739-8611
Mailing Address - Fax:307-739-8613
Practice Address - Street 1:1160 ALPINE LANE
Practice Address - Street 2:#1D
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83002
Practice Address - Country:US
Practice Address - Phone:307-739-8611
Practice Address - Fax:307-739-8613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119386400Medicaid