Provider Demographics
NPI:1881711174
Name:KINCHELOE DENTAL OFFICE, PC
Entity type:Organization
Organization Name:KINCHELOE DENTAL OFFICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:B
Authorized Official - Last Name:KINCHELOE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-638-8520
Mailing Address - Street 1:2625 WILDHORSE TRL
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-2232
Mailing Address - Country:US
Mailing Address - Phone:307-638-6544
Mailing Address - Fax:
Practice Address - Street 1:6244 YELLOWSTONE RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-3432
Practice Address - Country:US
Practice Address - Phone:307-638-8520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty