MEDICARE: NCDI - ANIMAS PROFESSIONAL, LLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	8446	CO

General Provider Information

NPI Number	:	1104277482
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NCDI - ANIMAS PROFESSIONAL, LLP

Provider Business Mailing Address
First Line	:	1220 OAK PARK DR
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-7348
Country	:	US
Telephone Number	:	970-223-8687
Fax Number	:

Provider Business Practice Location Address
First Line	:	2650 E PINON FRONTAGE RD
Second Line	:	BLDG #200
City	:	FARMINGTON
State	:	NM
Zip	:	87402-5084
Country	:	US
Telephone Number	:	505-599-9359
Fax Number	:

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	MARK D CRANE
Credential	:	D.D.S., M.S.
Telephone Number	:	970-223-8687

Provider Enumeration Date	:	06/28/2016
Last Update Date	:	06/28/2016

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