Healthcare Provider Details

I. General information

NPI: 1528540853
Provider Name (Legal Business Name): ALLIANCE DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 09/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12253 E 104TH PL UNIT 105
COMMERCE CITY CO
80022-2096
US

IV. Provider business mailing address

12253 E 104TH PL UNIT 105
COMMERCE CITY CO
80022-2096
US

V. Phone/Fax

Practice location:
  • Phone: 303-853-8000
  • Fax: 303-288-2219
Mailing address:
  • Phone: 303-853-8000
  • Fax: 303-288-2219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN00202825
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH.000903823
License Number StateCO

VIII. Authorized Official

Name: JENNIE MACUMBER
Title or Position: MEMBER/MANAGER
Credential:
Phone: 303-829-9243