Provider Demographics
NPI:1427421676
Name:CHEYENNE FACIAL IMAGING CENTER
Entity type:Organization
Organization Name:CHEYENNE FACIAL IMAGING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:L
Authorized Official - Last Name:BIRD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-316-4101
Mailing Address - Street 1:1401 AIRPORT PKWY STE 210
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-1541
Mailing Address - Country:US
Mailing Address - Phone:307-316-4101
Mailing Address - Fax:307-224-1089
Practice Address - Street 1:1401 AIRPORT PKWY STE 210
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1541
Practice Address - Country:US
Practice Address - Phone:307-316-4101
Practice Address - Fax:307-224-1089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY9991223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121770400Medicaid