Healthcare Provider Details

I. General information

NPI: 1811972094
Provider Name (Legal Business Name): SOUTHMOOR PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2005
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6850 E HAMPDEN AVE
DENVER CO
80224-3024
US

IV. Provider business mailing address

6850 E HAMPDEN AVE
DENVER CO
80224-3024
US

V. Phone/Fax

Practice location:
  • Phone: 303-758-6057
  • Fax: 303-692-9655
Mailing address:
  • Phone: 303-758-6057
  • Fax: 303-692-9655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number04949
License Number StateCO

VIII. Authorized Official

Name: DR. BRADLEY R. SMITH
Title or Position: PRESIDENT
Credential:
Phone: 303-799-1872