Healthcare Provider Details

I. General information

NPI: 1801863303
Provider Name (Legal Business Name): PERIODONTAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 S PEORIA ST BUILDING D
AURORA CO
80014-3182
US

IV. Provider business mailing address

2900 S PEORIA ST BUILDING D
AURORA CO
80014-3182
US

V. Phone/Fax

Practice location:
  • Phone: 303-755-4500
  • Fax: 303-755-4047
Mailing address:
  • Phone: 303-755-4500
  • Fax: 303-755-4047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number StateCO

VIII. Authorized Official

Name: DR. KENNETH J VERSMAN
Title or Position: PARTNER
Credential: D.D.S.
Phone: 303-755-4500