| Full Name | |
|---|---|
| Speciality | Dentist |
| Location | 112 High Street, Buffalo, Wyoming |
| Authorized Official Name and Position | Brian Jerome Cotant (OWNER DENTIST) |
| Authorized Official Contact | 3076842733 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 126 112 High Street Buffalo WY 82834 Ph: (307) 684-2733 | 112 High Street Buffalo WY 82834 Ph: (307) 684-2733 |
| NPI Number | 1366502726 |
|---|---|
| Provider Enumeration Date | 12/08/2006 |
| Last Update Date | 03/25/2015 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1366502726 | NPI | - | NPPES |
| 121328800 | Medicaid | WY | |
| 121329600 | Medicaid | WY |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | 1129 (Wyoming) | Primary |
| 124Q00000X | Dental Hygienist | 807 (Wyoming) | Secondary |
| 124Q00000X | Dental Hygienist | 841 (Wyoming) | Secondary |
Eagle Summit Dental Clinic, Inc Dental Clinic Medicare: Not Enrolled in Medicare Practice Location: 1001 Eagle View Dr, Buffalo, WY 82834 Phone: 307-684-0119 Fax: 307-684-0120 | |