Healthcare Provider Details

I. General information

NPI: 1265067425
Provider Name (Legal Business Name): MOBILE OUTREACH ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2020
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8422 W 78TH CIR
ARVADA CO
80005-4407
US

IV. Provider business mailing address

8422 W 78TH CIR
ARVADA CO
80005-4407
US

V. Phone/Fax

Practice location:
  • Phone: 303-506-4698
  • Fax:
Mailing address:
  • Phone: 303-506-4698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: OLGA ROMANOVNA KOGAN
Title or Position: CEO
Credential:
Phone: 303-506-4698