| NPI | 1194205401 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JASON WHITING Owner 307-635-2419 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WY 1199) |
| Additional Taxonomies | 122300000X Dentist (Licence: WY 1490) |
| Enumeration Date | 2018-08-16 |
| Last Update Date | 2018-08-16 |