Provider Demographics
NPI:1649488743
Name:CHILDREN'S DENTISTRY LLC
Entity type:Organization
Organization Name:CHILDREN'S DENTISTRY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-635-9251
Mailing Address - Street 1:6900 YELLOWTAIL RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-6102
Mailing Address - Country:US
Mailing Address - Phone:307-635-9251
Mailing Address - Fax:307-635-9218
Practice Address - Street 1:6900 YELLOWTAIL RD STE 100
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-6102
Practice Address - Country:US
Practice Address - Phone:307-635-9251
Practice Address - Fax:307-635-9218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2024-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY11081223P0221X
1223G0001X, 1223X0400X, 1223P0221X
WY10401223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119846700Medicaid
WY119256600Medicaid