Provider Demographics
NPI:1437882354
Name:WYOMING DENTAL LLC
Entity Type:Organization
Organization Name:WYOMING DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROHLF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-462-5150
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MN
Mailing Address - Zip Code:55092-0189
Mailing Address - Country:US
Mailing Address - Phone:651-462-5150
Mailing Address - Fax:651-462-1092
Practice Address - Street 1:5378 E VIKING BLVD
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MN
Practice Address - Zip Code:55092
Practice Address - Country:US
Practice Address - Phone:651-462-5150
Practice Address - Fax:651-462-1092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-07
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty