Provider Demographics
NPI:1801337902
Name:DENTAL ARTS PC
Entity type:Organization
Organization Name:DENTAL ARTS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:K
Authorized Official - Last Name:WALGREN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-745-8513
Mailing Address - Street 1:3421 E GARFIELD ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-5163
Mailing Address - Country:US
Mailing Address - Phone:307-745-8513
Mailing Address - Fax:307-745-0263
Practice Address - Street 1:3421 E GARFIELD ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-5163
Practice Address - Country:US
Practice Address - Phone:307-745-8513
Practice Address - Fax:307-745-0263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY921261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY112311400Medicaid