Provider Demographics
NPI:1487635926
Name:AESTHETIC DENTISTRY PC
Entity Type:Organization
Organization Name:AESTHETIC DENTISTRY PC
Other - Org Name:ERIC A DZIURDZIEL DDS & MARY KAY KRIVY DDS PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DDS DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:KRIVY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-632-6597
Mailing Address - Street 1:2029 BLUEGRASS CIR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-7368
Mailing Address - Country:US
Mailing Address - Phone:307-632-6597
Mailing Address - Fax:307-632-2170
Practice Address - Street 1:2029 BLUEGRASS CIR
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-7368
Practice Address - Country:US
Practice Address - Phone:307-632-6597
Practice Address - Fax:307-632-2170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYWY9631223G0001X
WYWY9671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty