Provider Demographics
NPI:1497394068
Name:STAR VALLEY DENTAL 1 LLC
Entity Type:Organization
Organization Name:STAR VALLEY DENTAL 1 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HOKANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-248-0741
Mailing Address - Street 1:PO BOX 1390
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:WY
Mailing Address - Zip Code:83110-1390
Mailing Address - Country:US
Mailing Address - Phone:307-885-4355
Mailing Address - Fax:
Practice Address - Street 1:725 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:WY
Practice Address - Zip Code:83110-1390
Practice Address - Country:US
Practice Address - Phone:307-885-4355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-31
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY137718300Medicaid