1356630057 NPI number — WYOMING ORAL & MAXILLOFACIAL SURGERY P. C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356630057 NPI number — WYOMING ORAL & MAXILLOFACIAL SURGERY P. C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYOMING ORAL & MAXILLOFACIAL SURGERY P. C.
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:
Provider Other Organization Name Type Code:
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:
1356630057
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4611 ARROYO DR SUITE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CASPER
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-235-1600
Provider Business Mailing Address Fax Number:
307-235-1601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4611 ARROYO DR SUITE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASPER
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-235-1600
Provider Business Practice Location Address Fax Number:
307-235-1601
Provider Enumeration Date:
04/04/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HARDY
Authorized Official First Name:
LUCAS
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
307-235-1600

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  1265 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223S0112X , with the licence number: 1146 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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