Provider Demographics
NPI:1356817118
Name:GREYBULL DENTAL
Entity Type:Organization
Organization Name:GREYBULL DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:ELDON
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:307-548-7654
Mailing Address - Street 1:240 E. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:LOVELL
Mailing Address - State:WY
Mailing Address - Zip Code:82431
Mailing Address - Country:US
Mailing Address - Phone:307-548-7654
Mailing Address - Fax:
Practice Address - Street 1:337 GREYBULL AVE
Practice Address - Street 2:
Practice Address - City:GREYBULL
Practice Address - State:WY
Practice Address - Zip Code:82426
Practice Address - Country:US
Practice Address - Phone:307-548-7654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-19
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty