=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033118179
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOUIS RAY GERKEN D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2005
-----------------------------------------------------
Last Update Date | 04/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2800 MADISON SQUARE DR SUITE 1
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80538-3358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-669-7711
-----------------------------------------------------
Fax | 970-669-2491
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2800 MADISON SQUARE DR SUITE 1
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80538-3358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-669-7711
-----------------------------------------------------
Fax | 970-669-2491
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 100946
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------