Healthcare Provider Details

I. General information

NPI: 1376733501
Provider Name (Legal Business Name): AAA FAMILY DENTAL CENTER III PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 6TH ST
GEORGETOWN CO
80444-1022
US

IV. Provider business mailing address

PO BOX 1022
GEORGETOWN CO
80444-1022
US

V. Phone/Fax

Practice location:
  • Phone: 303-569-3141
  • Fax: 303-569-3041
Mailing address:
  • Phone: 303-569-3141
  • Fax: 303-569-3041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number105584
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number105584
License Number StateCO

VIII. Authorized Official

Name: THOMAS LOSACCO
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 303-569-3141