=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033650015
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FORT MOGAN DENTAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2017
-----------------------------------------------------
Last Update Date | 03/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 617 WEST PLATTE AVE AREA A
-----------------------------------------------------
City | FORT MORGAN
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80701-9306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-867-4700
-----------------------------------------------------
Fax | 970-867-2128
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 617 WEST PLATTE AVE AREA A
-----------------------------------------------------
City | FORT MORGAN
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80701-9306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-867-2128
-----------------------------------------------------
Fax | 970-867-2128
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | TACI COOPER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 719-383-2083
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 00202298
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 00202298
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------