Provider Demographics
NPI:1821610957
Name:STAR VALLEY ORAL SURGERY
Entity Type:Organization
Organization Name:STAR VALLEY ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WESTON
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:307-883-4222
Mailing Address - Street 1:PO BOX 1365
Mailing Address - Street 2:
Mailing Address - City:THAYNE
Mailing Address - State:WY
Mailing Address - Zip Code:83127-1365
Mailing Address - Country:US
Mailing Address - Phone:307-883-4222
Mailing Address - Fax:307-883-4223
Practice Address - Street 1:487 N MAIN
Practice Address - Street 2:SUITE B
Practice Address - City:THAYNE
Practice Address - State:WY
Practice Address - Zip Code:83127
Practice Address - Country:US
Practice Address - Phone:307-883-4222
Practice Address - Fax:307-883-4222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty