MEDICARE: AWESOME SMILES, P.C.

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	:	1609904101
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AWESOME SMILES, P.C.

Provider Business Mailing Address
First Line	:	2700 MADISON SQUARE DR
Second Line	:
City	:	LOVELAND
State	:	CO
Zip	:	80538-3385
Country	:	US
Telephone Number	:	970-669-1122
Fax Number	:	970-669-1984

Provider Business Practice Location Address
First Line	:	2700 MADISON SQUARE DR
Second Line	:
City	:	LOVELAND
State	:	CO
Zip	:	80538-3385
Country	:	US
Telephone Number	:	970-669-1122
Fax Number	:	970-669-1984

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. TOBIAS M. DERLOSHON
Credential	:	D.D.S.
Telephone Number	:	970-669-1122

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	05/13/2014

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