Healthcare Provider Details

I. General information

NPI: 1306507736
Provider Name (Legal Business Name): MOUNTAIN SMILES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2022
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 35TH ST
DENVER CO
80205
US

IV. Provider business mailing address

1225 35TH ST
DENVER CO
80205
US

V. Phone/Fax

Practice location:
  • Phone: 720-440-7743
  • Fax: 719-414-0027
Mailing address:
  • Phone: 720-440-7743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: JOHN LYDIATT
Title or Position: OWNER DENTIST
Credential: DDS
Phone: 719-599-5700