1649488743 NPI number — CHILDREN'S DENTISTRY LLC

Table of content: (NPI 1649488743)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649488743 NPI number — CHILDREN'S DENTISTRY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDREN'S DENTISTRY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE SMILE ACADEMY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649488743
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6900 YELLOWTAIL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHEYENNE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82009-6102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-635-9251
Provider Business Mailing Address Fax Number:
307-635-9218

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6900 YELLOWTAIL RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHEYENNE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82009-6102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-635-9251
Provider Business Practice Location Address Fax Number:
307-635-9218
Provider Enumeration Date:
05/21/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CANTINE
Authorized Official First Name:
MOLLY
Authorized Official Middle Name:
Authorized Official Title or Position:
INSURANCE COORDINATOR
Authorized Official Telephone Number:
307-635-9251

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: 1040 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: 1108 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)