Provider Demographics
NPI:1346923133
Name:WY SPECIALTY DENTAL SERVICES, LLC
Entity Type:Organization
Organization Name:WY SPECIALTY DENTAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING AND PR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:
Authorized Official - Last Name:DASCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-638-0303
Mailing Address - Street 1:1610 54TH AVE N STE 205
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209-1442
Mailing Address - Country:US
Mailing Address - Phone:504-638-0303
Mailing Address - Fax:
Practice Address - Street 1:2670 OAKCREST DR
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-5905
Practice Address - Country:US
Practice Address - Phone:307-257-8029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WY SPECIALTY DENTAL SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty