Provider Demographics
NPI:1326127234
Name:CHEYENNE PERIODONTICS, PC
Entity Type:Organization
Organization Name:CHEYENNE PERIODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:VAN GINKEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-632-4574
Mailing Address - Street 1:1401 AIRPORT PKWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-1518
Mailing Address - Country:US
Mailing Address - Phone:307-632-4574
Mailing Address - Fax:307-632-4574
Practice Address - Street 1:1401 AIRPORT PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1518
Practice Address - Country:US
Practice Address - Phone:307-632-4574
Practice Address - Fax:307-632-4574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2012-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8901223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty