Provider Demographics
NPI:1629441290
Name:OIL CITY DENTAL LLC
Entity Type:Organization
Organization Name:OIL CITY DENTAL LLC
Other - Org Name:TRU DENTAL LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIE
Authorized Official - Middle Name:JO
Authorized Official - Last Name:MOONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-577-0577
Mailing Address - Street 1:1347 S BEVERLY ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-4133
Mailing Address - Country:US
Mailing Address - Phone:307-577-0577
Mailing Address - Fax:307-234-4655
Practice Address - Street 1:1347 S BEVERLY ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4133
Practice Address - Country:US
Practice Address - Phone:307-577-0577
Practice Address - Fax:307-234-4655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-04
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY12331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY120733400Medicaid
WY1023343852Medicaid