Healthcare Provider Details

I. General information

NPI: 1740834381
Provider Name (Legal Business Name): COLORADO DENTAL SPECIALIST PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2019
Last Update Date: 07/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 W 120TH AVE STE 800
WESTMINSTER CO
80234-2747
US

IV. Provider business mailing address

1005 W 120TH AVE STE 800
WESTMINSTER CO
80234-2747
US

V. Phone/Fax

Practice location:
  • Phone: 720-263-5420
  • Fax:
Mailing address:
  • Phone: 720-263-5420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE JOHNSON
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 509-315-8338