Provider Demographics
NPI:1508322603
Name:BLACKS FORK DENTAL, PC
Entity Type:Organization
Organization Name:BLACKS FORK DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:REN
Authorized Official - Last Name:LESTER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:307-782-3630
Mailing Address - Street 1:PO BOX 356
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:WY
Mailing Address - Zip Code:82939-0356
Mailing Address - Country:US
Mailing Address - Phone:307-782-3630
Mailing Address - Fax:
Practice Address - Street 1:650 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:MT VIEW
Practice Address - State:WY
Practice Address - Zip Code:82939
Practice Address - Country:US
Practice Address - Phone:307-782-3630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental