Provider Demographics
NPI:1881194280
Name:2ND STREET DENTAL, LLC
Entity type:Organization
Organization Name:2ND STREET DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HAEFELE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-337-3717
Mailing Address - Street 1:2546 E 2ND ST STE 300
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-2062
Mailing Address - Country:US
Mailing Address - Phone:307-337-3717
Mailing Address - Fax:
Practice Address - Street 1:2546 E 2ND ST STE 300
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-2062
Practice Address - Country:US
Practice Address - Phone:307-337-3717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1316261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental