Provider Demographics
NPI:1902147275
Name:SHERIDAN WYO DENTAL
Entity Type:Organization
Organization Name:SHERIDAN WYO DENTAL
Other - Org Name:HAL QUIST, DDS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:QUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-672-2328
Mailing Address - Street 1:2 N MAIN ST
Mailing Address - Street 2:STE 405
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-6318
Mailing Address - Country:US
Mailing Address - Phone:307-672-7439
Mailing Address - Fax:
Practice Address - Street 1:2 N MAIN ST
Practice Address - Street 2:STE 405
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-6318
Practice Address - Country:US
Practice Address - Phone:307-672-7439
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106690100Medicaid