Healthcare Provider Details

I. General information

NPI: 1700645876
Provider Name (Legal Business Name): LANDMARK DENTAL STUDIO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 03/18/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5425 LANDMARK PL STE 307
GREENWOOD VILLAGE CO
80111-1951
US

IV. Provider business mailing address

5425 LANDMARK PL STE 307
GREENWOOD VILLAGE CO
80111-1951
US

V. Phone/Fax

Practice location:
  • Phone: 303-773-8012
  • Fax: 720-367-1011
Mailing address:
  • Phone: 303-773-8012
  • Fax: 720-367-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. RYAN SCOTT MICKLE
Title or Position: DENTIST/PARTNER
Credential: DDS
Phone: 303-505-1015