Provider Demographics
NPI:1013289966
Name:GILLETTE PEDIATRIC DENTISTRY LLC
Entity type:Organization
Organization Name:GILLETTE PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-670-8118
Mailing Address - Street 1:530 RUNNING W DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-2003
Mailing Address - Country:US
Mailing Address - Phone:307-670-8118
Mailing Address - Fax:
Practice Address - Street 1:433 SHADOW RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-9350
Practice Address - Country:US
Practice Address - Phone:307-670-8118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-07
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY12711223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty