Provider Demographics
NPI:1467561167
Name:BOZEMAN TRAIL ORTHODONTICS PC
Entity Type:Organization
Organization Name:BOZEMAN TRAIL ORTHODONTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:WETZEL
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-237-8419
Mailing Address - Street 1:932 SOUTH DAVID ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601
Mailing Address - Country:US
Mailing Address - Phone:307-237-8419
Mailing Address - Fax:307-234-4912
Practice Address - Street 1:932 SOUTH DAVID ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601
Practice Address - Country:US
Practice Address - Phone:307-237-8419
Practice Address - Fax:307-234-4912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY546261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental