Provider Demographics
NPI:1679952865
Name:DENISE R PRUGH DDS
Entity type:Organization
Organization Name:DENISE R PRUGH DDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:ROBIN
Authorized Official - Last Name:PRUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-265-7878
Mailing Address - Street 1:295 N WALSH DR
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-1911
Mailing Address - Country:US
Mailing Address - Phone:307-265-7878
Mailing Address - Fax:
Practice Address - Street 1:295 N WALSH DR
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-1911
Practice Address - Country:US
Practice Address - Phone:307-265-7878
Practice Address - Fax:307-268-4953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY114491000Medicaid