| NPI | 1073973780 |
|---|---|
| Doing Business As | GRAND AVENUE DENTAL CENTER |
| Entity Type | Organization |
| Authorized Contact | JENNIFER RAE DOSER President 307-742-0722 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WY 1255) |
| Additional Taxonomies | 332BC3200X Durable Medical Equipment & Medical Supplies, Customized Equipment |
| Enumeration Date | 2016-02-24 |
| Last Update Date | 2016-08-25 |