Healthcare Provider Details

I. General information

NPI: 1609390632
Provider Name (Legal Business Name): 38TH MODERN DENTAL PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2017
Last Update Date: 08/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 W 38TH AVE. #5
DENVER CO
80211
US

IV. Provider business mailing address

6020 N CAREFREE CIR
COLORADO SPRINGS CO
80922-2402
US

V. Phone/Fax

Practice location:
  • Phone: 303-515-7008
  • Fax: 888-790-7062
Mailing address:
  • Phone: 719-266-2717
  • Fax: 888-790-7062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: SCOTT FREDERICK
Title or Position: OWNER
Credential: DDS
Phone: 303-515-7008