Provider Demographics
NPI:1306190749
Name:CLOETTA, REBECCA E (DDS)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:E
Last Name:CLOETTA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11570
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-1570
Mailing Address - Country:US
Mailing Address - Phone:307-733-4122
Mailing Address - Fax:307-733-4164
Practice Address - Street 1:1315 S HWY 89
Practice Address - Street 2:SUITE 102
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83002-1570
Practice Address - Country:US
Practice Address - Phone:307-733-4122
Practice Address - Fax:307-733-4164
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-07
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1009122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY122780700Medicaid