Provider Demographics
NPI:1417351602
Name:ASPEN HILLS DENTAL LLC
Entity Type:Organization
Organization Name:ASPEN HILLS DENTAL LLC
Other - Org Name:LIVINGSTON DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS LEADER
Authorized Official - Prefix:
Authorized Official - First Name:JEANELLE
Authorized Official - Middle Name:ELMOYNE
Authorized Official - Last Name:LIVINGSTON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:307-885-4337
Mailing Address - Street 1:800 SOUTH WASHINGTON ST.
Mailing Address - Street 2:800 SOUTH WASHINGTON
Mailing Address - City:AFTON
Mailing Address - State:WY
Mailing Address - Zip Code:83110
Mailing Address - Country:US
Mailing Address - Phone:307-885-4337
Mailing Address - Fax:307-885-4334
Practice Address - Street 1:800 SOUTH WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:WY
Practice Address - Zip Code:83110
Practice Address - Country:US
Practice Address - Phone:307-885-4337
Practice Address - Fax:307-885-4334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-16
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY910122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY112487100Medicaid