Provider Demographics
NPI:1225748049
Name:BLUE SKIES DENTAL LLC
Entity Type:Organization
Organization Name:BLUE SKIES DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:WYMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:785-392-0770
Mailing Address - Street 1:3863 HAYOVEL PL
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66503-8529
Mailing Address - Country:US
Mailing Address - Phone:785-392-0770
Mailing Address - Fax:
Practice Address - Street 1:4201 ANDERSON AVE
Practice Address - Street 2:STE A
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66503-7601
Practice Address - Country:US
Practice Address - Phone:785-537-4337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-02
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment