MEDICARE: LOUISVILLE DENTAL SPECIALTIES AND IMPLANT CENTER

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1902750649
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOUISVILLE DENTAL SPECIALTIES AND IMPLANT CENTER

Provider Business Mailing Address
First Line	:	1075 E SOUTH BOULDER RD STE 135
Second Line	:
City	:	LOUISVILLE
State	:	CO
Zip	:	80027-2559
Country	:	US
Telephone Number	:	303-665-2377
Fax Number	:

Provider Business Practice Location Address
First Line	:	1075 E SOUTH BOULDER RD STE 135
Second Line	:
City	:	LOUISVILLE
State	:	CO
Zip	:	80027-2559
Country	:	US
Telephone Number	:	303-665-2377
Fax Number	:

Authorized Official
Title or Position	:	ADMIN
Name	:	RON BERGLOFF
Credential	:
Telephone Number	:	720-431-6060

Provider Enumeration Date	:	02/20/2026
Last Update Date	:	02/20/2026

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