Provider Demographics
NPI:1740942002
Name:SOH OF WYOMING LLC
Entity type:Organization
Organization Name:SOH OF WYOMING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ASHLY
Authorized Official - Middle Name:KRISTINE
Authorized Official - Last Name:SUNSHINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-413-2803
Mailing Address - Street 1:121 W CARLSON ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4044
Mailing Address - Country:US
Mailing Address - Phone:307-635-1197
Mailing Address - Fax:
Practice Address - Street 1:121 W CARLSON ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4044
Practice Address - Country:US
Practice Address - Phone:307-635-1197
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOH OF WYOMING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-10-13
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty