Provider Demographics
NPI:1548518566
Name:DEER CREEK DENTAL
Entity type:Organization
Organization Name:DEER CREEK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:K
Authorized Official - Last Name:NEUBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-235-5344
Mailing Address - Street 1:514 S DURBIN ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-3150
Mailing Address - Country:US
Mailing Address - Phone:307-235-5344
Mailing Address - Fax:307-473-8588
Practice Address - Street 1:514 S DURBIN ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-3150
Practice Address - Country:US
Practice Address - Phone:307-235-5344
Practice Address - Fax:307-473-8588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-23
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY840122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY103529100Medicaid