Provider Demographics
NPI:1902098528
Name:LANDER DENTAL GROUP,PC
Entity Type:Organization
Organization Name:LANDER DENTAL GROUP,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-332-7710
Mailing Address - Street 1:799 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3703
Mailing Address - Country:US
Mailing Address - Phone:307-332-7710
Mailing Address - Fax:
Practice Address - Street 1:799 S 2ND ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3703
Practice Address - Country:US
Practice Address - Phone:307-332-7710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LANDER DENTAL GROUP, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-16
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118366400Medicaid