Healthcare Provider Details

I. General information

NPI: 1124128368
Provider Name (Legal Business Name): ALLEN KVIDERA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 VILLAGE PLACE
DILLON CO
80435
US

IV. Provider business mailing address

PO BOX 65
SILVERTHORNE CO
80498-0065
US

V. Phone/Fax

Practice location:
  • Phone: 563-940-0751
  • Fax:
Mailing address:
  • Phone: 563-940-0751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number8537
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: