Provider Demographics
NPI:1508532482
Name:2BREWERSANDACANUCKDENTAL LLC
Entity Type:Organization
Organization Name:2BREWERSANDACANUCKDENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ARGYLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-789-5210
Mailing Address - Street 1:50 ARROWHEAD DR
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-9243
Mailing Address - Country:US
Mailing Address - Phone:307-789-5210
Mailing Address - Fax:
Practice Address - Street 1:50 ARROWHEAD DR
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-9243
Practice Address - Country:US
Practice Address - Phone:307-789-5210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY140937900Medicaid
WY125569000Medicaid
WY119553100Medicaid