Provider Demographics
NPI:1689117608
Name:JC DENTISTRY LLC
Entity Type:Organization
Organization Name:JC DENTISTRY LLC
Other - Org Name:BROOKSIDE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:B
Authorized Official - Last Name:CHRISTOPHERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-635-6300
Mailing Address - Street 1:229 STOREY BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-3595
Mailing Address - Country:US
Mailing Address - Phone:307-635-6300
Mailing Address - Fax:307-635-6361
Practice Address - Street 1:229 STOREY BLVD STE A
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-3595
Practice Address - Country:US
Practice Address - Phone:307-635-6300
Practice Address - Fax:307-635-6361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-22
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY14161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty