Healthcare Provider Details

I. General information

NPI: 1528449915
Provider Name (Legal Business Name): MODERN DENTAL PROFESSIONALS CO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7611 W COLFAX AVE UNIT D
LAKEWOOD CO
80214-5424
US

IV. Provider business mailing address

PO BOX 25153
SANTA ANA CA
92799-5153
US

V. Phone/Fax

Practice location:
  • Phone: 303-202-0900
  • Fax: 303-202-0901
Mailing address:
  • Phone: 714-578-6358
  • Fax: 949-242-2631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number105734
License Number StateCO

VIII. Authorized Official

Name: DR. CRAIG A MELLOR
Title or Position: PC OWNER
Credential: DDS
Phone: 303-442-3434