Healthcare Provider Details

I. General information

NPI: 1215240882
Provider Name (Legal Business Name): NEW IMAGE DENTAL IMPLANT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2010
Last Update Date: 07/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 E 1ST AVE
DENVER CO
80206-7510
US

IV. Provider business mailing address

3737 E 1ST AVE
DENVER CO
80206-7510
US

V. Phone/Fax

Practice location:
  • Phone: 303-321-8400
  • Fax:
Mailing address:
  • Phone: 303-321-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberCO-7149
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberCO-104214
License Number StateCO

VIII. Authorized Official

Name: JENNIFER LYNN MILLER
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 303-321-8400