Healthcare Provider Details

I. General information

NPI: 1124581665
Provider Name (Legal Business Name): EMBRACEKIDS V A PROFESSIONAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 04/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 S MONACO PKWY
DENVER CO
80222-5814
US

IV. Provider business mailing address

5865 E POWERS AVE
GREENWOOD VILLAGE CO
80111-1545
US

V. Phone/Fax

Practice location:
  • Phone: 303-476-6233
  • Fax:
Mailing address:
  • Phone: 303-476-6233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: OWEN NIEBERG
Title or Position: COO
Credential:
Phone: 917-224-8171