Provider Demographics
NPI:1821696022
Name:WYOMING FAMILY DENTAL
Entity Type:Organization
Organization Name:WYOMING FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:
Authorized Official - Last Name:VEUGELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-462-5150
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MN
Mailing Address - Zip Code:55092
Mailing Address - Country:US
Mailing Address - Phone:651-462-5150
Mailing Address - Fax:
Practice Address - Street 1:5378 EAST VIKING BLVD.
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MN
Practice Address - Zip Code:55092
Practice Address - Country:US
Practice Address - Phone:651-462-5150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty