Healthcare Provider Details

I. General information

NPI: 1215194543
Provider Name (Legal Business Name): FORT LUPTON DENTAL GROUP P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 DENVER AVE
FORT LUPTON CO
80621-1819
US

IV. Provider business mailing address

229 DENVER AVE
FORT LUPTON CO
80621-1819
US

V. Phone/Fax

Practice location:
  • Phone: 303-857-4377
  • Fax:
Mailing address:
  • Phone: 303-857-4377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberHD104267
License Number StateCO

VIII. Authorized Official

Name: DR. IRENE MARGARET HOLLOMA
Title or Position: OWNER DENTIST
Credential: D.D.S.
Phone: 303-857-4377