Healthcare Provider Details

I. General information

NPI: 1568770162
Provider Name (Legal Business Name): PERFECT TEETH-SPECIALTY CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2010
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1699 S COLORADO BLVD BUILDING A, SUITE J
DENVER CO
80222-4036
US

IV. Provider business mailing address

7160 DALLAS PKWY STE 400
PLANO TX
75024-7111
US

V. Phone/Fax

Practice location:
  • Phone: 303-639-6000
  • Fax:
Mailing address:
  • Phone: 254-216-0661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number10196
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number10278
License Number StateCO

VIII. Authorized Official

Name: ANGEL K MARTIN
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 254-216-0661