Provider Demographics
NPI:1710004569
Name:WHISKEY MOUNTAIN DENTAL
Entity Type:Organization
Organization Name:WHISKEY MOUNTAIN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER DENTAL ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-455-2229
Mailing Address - Street 1:PO BOX 783
Mailing Address - Street 2:
Mailing Address - City:DUBOIS
Mailing Address - State:WY
Mailing Address - Zip Code:82513-0783
Mailing Address - Country:US
Mailing Address - Phone:307-455-2229
Mailing Address - Fax:
Practice Address - Street 1:108 NORTH 1ST STREET
Practice Address - Street 2:
Practice Address - City:DUBOIS
Practice Address - State:WY
Practice Address - Zip Code:82513
Practice Address - Country:US
Practice Address - Phone:307-455-2029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty