Provider Demographics
NPI:1174942122
Name:BARNES, BREANNA
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:BARNES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1439 STILLWATER AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-7367
Mailing Address - Country:US
Mailing Address - Phone:307-778-7100
Mailing Address - Fax:
Practice Address - Street 1:1439 STILLWATER AVE STE 7
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-7367
Practice Address - Country:US
Practice Address - Phone:307-778-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-07
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61240122300000X, 1223P0221X
WY15071223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY004134062OtherUNITED CONCORDIA DENTAL