Provider Demographics
NPI:1922110147
Name:SUGARLAND DENTAL PC
Entity Type:Organization
Organization Name:SUGARLAND DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT SUGARLAND DENTAL PC
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-673-5522
Mailing Address - Street 1:941A SUGARLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801
Mailing Address - Country:US
Mailing Address - Phone:307-673-5522
Mailing Address - Fax:307-673-0658
Practice Address - Street 1:941A SUGARLAND DRIVE
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801
Practice Address - Country:US
Practice Address - Phone:307-673-5522
Practice Address - Fax:307-673-0658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10301223G0001X
NC62911223G0001X
AK10171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY120907800Medicaid
WY=========OtherDELTA DENTAL KID CARE