MEDICARE: DYLAN KOPEL KINTISH

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1902259062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DYLAN KOPEL KINTISH

Provider Business Mailing Address
First Line	:	3201 S SHERMAN ST APT 8
Second Line	:
City	:	ENGLEWOOD
State	:	CO
Zip	:	80113-2643
Country	:	US
Telephone Number	:	978-578-4853
Fax Number	:

Provider Business Practice Location Address
First Line	:	11059 E BETHANY DR
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80014-2622
Country	:	US
Telephone Number	:	302-617-2300
Fax Number	:	303-617-2365

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2016
Last Update Date	:	07/13/2016

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