Provider Demographics
NPI:1780745190
Name:FELLER AND FELLER ORTHODONTICS, LLC
Entity type:Organization
Organization Name:FELLER AND FELLER ORTHODONTICS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PARLEY
Authorized Official - Middle Name:JACK
Authorized Official - Last Name:FELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:307-362-8842
Mailing Address - Street 1:2405 CASCADE DR
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-5652
Mailing Address - Country:US
Mailing Address - Phone:307-362-8842
Mailing Address - Fax:
Practice Address - Street 1:2405 CASCADE DR
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5652
Practice Address - Country:US
Practice Address - Phone:307-362-8842
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY11581223X0400X
WY7431223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
10578OtherUNITED CONCORDIA
WY743OtherDELTA DENTAL
WY=========Medicaid