Healthcare Provider Details

I. General information

NPI: 1659744589
Provider Name (Legal Business Name): SENIOR SMILES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2015
Last Update Date: 10/30/2015
Certification Date:
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:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number000904249
License Number StateCO

VIII. Authorized Official

Name: OLGA KOGAN
Title or Position: REGISTERED DENTAL HYGIENIST
Credential:
Phone: 303-506-4698