Healthcare Provider Details

I. General information

NPI: 1366896318
Provider Name (Legal Business Name): PDC LOS NINOS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2016
Last Update Date: 04/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 S SHERIDAN BLVD
DENVER CO
80232-8022
US

IV. Provider business mailing address

2476 N UNIVERSITY PKWY STE 201
PROVO UT
84604-3869
US

V. Phone/Fax

Practice location:
  • Phone: 303-777-5437
  • Fax:
Mailing address:
  • Phone: 801-305-3460
  • Fax: 801-692-9083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2924138903
License Number StateUT

VIII. Authorized Official

Name: KENDALL BRENT SKINNER
Title or Position: GENERAL DENTIST
Credential: DMD
Phone: 303-777-5437