Provider Demographics
NPI:1760856710
Name:ORAL & MAXILLOFACIAL SURGEONS OF WYOMING
Entity Type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGEONS OF WYOMING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:CANDLER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:307-389-2999
Mailing Address - Street 1:2297 N HILL FIELD RD # A105
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-6920
Mailing Address - Country:US
Mailing Address - Phone:801-779-0506
Mailing Address - Fax:
Practice Address - Street 1:2405 CASCADE DR
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5580
Practice Address - Country:US
Practice Address - Phone:307-389-2999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-13
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty