Provider Demographics
NPI:1295130631
Name:BIGHORN ORTHODONTICS LLC
Entity type:Organization
Organization Name:BIGHORN ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICAH
Authorized Official - Middle Name:G
Authorized Official - Last Name:MORTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:801-831-2662
Mailing Address - Street 1:642 VAL VISTA ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-3659
Mailing Address - Country:US
Mailing Address - Phone:307-672-6917
Mailing Address - Fax:
Practice Address - Street 1:642 VAL VISTA ST
Practice Address - Street 2:SUITE B
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-3659
Practice Address - Country:US
Practice Address - Phone:307-672-6917
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY13441223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty