Provider Demographics
NPI:1477792588
Name:DENTAL CARE OF FREMONT COUNTY
Entity Type:Organization
Organization Name:DENTAL CARE OF FREMONT COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:HAUCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-856-3463
Mailing Address - Street 1:1224 E JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3841
Mailing Address - Country:US
Mailing Address - Phone:307-856-3463
Mailing Address - Fax:307-856-9910
Practice Address - Street 1:1224 E JACKSON AVE
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-3841
Practice Address - Country:US
Practice Address - Phone:307-856-3463
Practice Address - Fax:307-856-9910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118488100Medicaid