Provider Demographics
NPI:1649575465
Name:BEAR RIVER DENTAL
Entity Type:Organization
Organization Name:BEAR RIVER DENTAL
Other - Org Name:NATHAN R. LESTER DMD PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:LESTER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:307-789-5608
Mailing Address - Street 1:50 PARK RD
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-2613
Mailing Address - Country:US
Mailing Address - Phone:307-789-5608
Mailing Address - Fax:307-789-4401
Practice Address - Street 1:50 PARK RD
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-2613
Practice Address - Country:US
Practice Address - Phone:307-789-5608
Practice Address - Fax:307-789-4401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1131122300000X
WY12501223S0112X
WY12571223S0112X
WY12021223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1023268299Medicaid
WY1558432120Medicaid
WY1689795114Medicaid
WY1063492981Medicaid