Provider Demographics
NPI:1982932265
Name:PAINTBRUSH DENTAL, PC
Entity Type:Organization
Organization Name:PAINTBRUSH DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEIF
Authorized Official - Middle Name:A
Authorized Official - Last Name:POLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-864-9411
Mailing Address - Street 1:110 E ARAPAHOE ST
Mailing Address - Street 2:PO BOX 751
Mailing Address - City:THERMOPOLIS
Mailing Address - State:WY
Mailing Address - Zip Code:82440-0751
Mailing Address - Country:US
Mailing Address - Phone:307-864-9411
Mailing Address - Fax:307-864-2756
Practice Address - Street 1:110 E ARAPAHOE ST
Practice Address - Street 2:
Practice Address - City:THERMOPOLIS
Practice Address - State:WY
Practice Address - Zip Code:82443
Practice Address - Country:US
Practice Address - Phone:307-864-9411
Practice Address - Fax:307-864-2756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-25
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1222261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental