Provider Demographics
NPI:1457877987
Name:DEER CREEK DENTISTRY, PC
Entity Type:Organization
Organization Name:DEER CREEK DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:RODNEY
Authorized Official - Last Name:ROCHELLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-235-5344
Mailing Address - Street 1:514 SOUTH DURBIN STREET
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601
Mailing Address - Country:US
Mailing Address - Phone:307-235-5344
Mailing Address - Fax:307-473-8588
Practice Address - Street 1:514 SOUTH DURBIN STREET
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601
Practice Address - Country:US
Practice Address - Phone:307-235-5344
Practice Address - Fax:307-473-8588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY13191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty