Provider Demographics
NPI:1457485732
Name:JACKSON FAMILY DENTISTRY
Entity Type:Organization
Organization Name:JACKSON FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARY
Authorized Official - Middle Name:G
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:307-733-7044
Mailing Address - Street 1:PO BOX 9248
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-9248
Mailing Address - Country:US
Mailing Address - Phone:307-733-7044
Mailing Address - Fax:307-734-1409
Practice Address - Street 1:1115 MAPLEWAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-733-7044
Practice Address - Fax:307-734-1409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY112319000Medicaid