Healthcare Provider Details

I. General information

NPI: 1265101356
Provider Name (Legal Business Name): MOUNTAIN DENTAL ANESTHESIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2021
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8683 E LINCOLN AVE STE 130
LONE TREE CO
80124-9812
US

IV. Provider business mailing address

12548 N 4TH ST
PARKER CO
80134-9458
US

V. Phone/Fax

Practice location:
  • Phone: 317-459-0738
  • Fax:
Mailing address:
  • Phone: 317-459-0738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number State

VIII. Authorized Official

Name: JOHN RUSSELL YANCEY
Title or Position: DENTIST ANESTHESIOLOGIST
Credential: DDS
Phone: 317-459-0738