Healthcare Provider Details

I. General information

NPI: 1861035412
Provider Name (Legal Business Name): EMBRACEKIDS V A PROFESSIONAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2019
Last Update Date: 10/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5375 W 38TH AVE
WHEAT RIDGE CO
80212-7058
US

IV. Provider business mailing address

5865 E POWERS AVE
GREENWOOD VILLAGE CO
80111-1545
US

V. Phone/Fax

Practice location:
  • Phone: 303-476-6292
  • Fax:
Mailing address:
  • Phone: 303-907-7978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: OWEN NIEBERG
Title or Position: COO
Credential:
Phone: 917-224-8171