Provider Demographics
NPI:1356630057
Name:WYOMING ORAL & MAXILLOFACIAL SURGERY P. C.
Entity Type:Organization
Organization Name:WYOMING ORAL & MAXILLOFACIAL SURGERY P. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUCAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:HARDY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:307-235-1600
Mailing Address - Street 1:4611 ARROYO DR SUITE 1
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604
Mailing Address - Country:US
Mailing Address - Phone:307-235-1600
Mailing Address - Fax:307-235-1601
Practice Address - Street 1:4611 ARROYO DR SUITE 1
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82604
Practice Address - Country:US
Practice Address - Phone:307-235-1600
Practice Address - Fax:307-235-1601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY11461223S0112X
WY12651223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty