| Organization Name: | PAINTBRUSH DENTAL, PC |
| NPI Number: | 1982932265 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | LEIF A POLSON (OWNER) |
| Mailing Address: | 110 E Arapahoe St Thermopolis |
| State: | WY US |
| Postal Code: | 82443 |
| Phone Number: | 3078649411 |
| Fax Number: | 3078642756 |
| NPI Enumeration Date: | 11/25/2009 |
| NPI Last Update Date: | 11/25/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QD0000X |
| License Number: | 1222 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WY |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Dental |
| Taxonomy Definition: | |