Healthcare Provider Details

I. General information

NPI: 1467868596
Provider Name (Legal Business Name): ADVANCED DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1557 W 84TH AVE UNIT 1
FEDERAL HEIGHTS CO
80260-4780
US

IV. Provider business mailing address

1557 W 84TH AVE UNIT 1
FEDERAL HEIGHTS CO
80260-4780
US

V. Phone/Fax

Practice location:
  • Phone: 303-426-4860
  • Fax: 303-426-1530
Mailing address:
  • Phone: 303-426-4860
  • Fax: 303-426-1530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8478
License Number StateCO

VIII. Authorized Official

Name: DR. JASON RONALD VAN WAGENEN
Title or Position: PARTNER
Credential:
Phone: 303-426-4860