MEDICARE: PROFESSIONAL DENTAL GROUP

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	122300000X	Dentist	7990	CO

General Provider Information

NPI Number	:	1548691520
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL DENTAL GROUP

Provider Business Mailing Address
First Line	:	1120 W SOUTH BOULDER RD STE 204
Second Line	:
City	:	LAFAYETTE
State	:	CO
Zip	:	80026-8952
Country	:	US
Telephone Number	:	720-638-2169
Fax Number	:	720-638-2931

Provider Business Practice Location Address
First Line	:	1120 W SOUTH BOULDER RD STE 204
Second Line	:
City	:	LAFAYETTE
State	:	CO
Zip	:	80026-8952
Country	:	US
Telephone Number	:	720-638-2169
Fax Number	:	720-638-2931

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DANIEL G. HILL
Credential	:	D.D.S.
Telephone Number	:	970-638-2169

Provider Enumeration Date	:	12/02/2013
Last Update Date	:	12/02/2013

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