Healthcare Provider Details

I. General information

NPI: 1083071047
Provider Name (Legal Business Name): JMJ III
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2016
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

491 FOREST EDGE RD
WOODLAND PARK CO
80863-2499
US

IV. Provider business mailing address

491 FOREST EDGE RD
WOODLAND PARK CO
80863-2499
US

V. Phone/Fax

Practice location:
  • Phone: 719-687-6366
  • Fax: 719-687-6388
Mailing address:
  • Phone: 719-687-6366
  • Fax: 719-687-6388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5676
License Number StateCO

VIII. Authorized Official

Name: MRS. RUTH G BISHOP
Title or Position: OFFICE MANAGER
Credential:
Phone: 719-687-6366