Healthcare Provider Details

I. General information

NPI: 1740856434
Provider Name (Legal Business Name): MARK VELEMIROVICH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 N LINCOLN AVE
LOVELAND CO
80537-4876
US

IV. Provider business mailing address

4176 KESTREL DR
BROOMFIELD CO
80023-3933
US

V. Phone/Fax

Practice location:
  • Phone: 970-541-2183
  • Fax:
Mailing address:
  • Phone: 615-636-3443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number00204728
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: