MEDICARE: NCDI LONGMONT 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

General Provider Information

NPI Number	:	1144830282
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NCDI LONGMONT 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	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1818 MOUNTAIN VIEW AVE
Second Line	:
City	:	LONGMONT
State	:	CO
Zip	:	80501-3253
Country	:	US
Telephone Number	:	970-223-8687
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	KATIE HAMBRIGHT
Credential	:
Telephone Number	:	970-223-8687

Provider Enumeration Date	:	08/04/2020
Last Update Date	:	08/04/2020

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