Provider Demographics
NPI:1194205401
Name:WYOMING COSMETIC AND FAMILY DENTAL
Entity Type:Organization
Organization Name:WYOMING COSMETIC AND FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITING
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:307-635-2419
Mailing Address - Street 1:4620 GRANDVIEW AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009
Mailing Address - Country:US
Mailing Address - Phone:307-635-2419
Mailing Address - Fax:307-772-3443
Practice Address - Street 1:4620 GRANDVIEW AVE
Practice Address - Street 2:SUITE #101
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009
Practice Address - Country:US
Practice Address - Phone:307-635-2419
Practice Address - Fax:307-772-3443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1199122300000X
WY1490122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty