=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013335918
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | M. DENTAL, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2014
-----------------------------------------------------
Last Update Date | 03/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 745 S. GARTRELL RD. UNIT A9
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80016-2439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-840-9447
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1777 S HARRISON ST STE. 1250
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80210-3925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-333-7733
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PERSONAL REPRESENTATIVE
-----------------------------------------------------
Name | CYNDI L. LYDEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 303-333-7733
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 7162
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------