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General NPI Number Information
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NPI Number | 1093121667
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Entity Type | Organization
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Legal Business Name | PATRA WATANA DMD PEDIATRIC DENTISTRY LLC
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Dates
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Enumeration Date | 07/03/2014
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Last Update Date | 07/03/2014
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Provider Practice Location Address
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Address Line | 8200 E. BELLEVIEW AVE. SUITE #420E
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City | GREENWOOD VILLAGE
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State | CO
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Zip | 80111
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Country | US
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Telephone | 303-740-7088
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Fax |
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Provider Business Mailing Address
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Address Line | 8200 E BELLEVIEW AVE SUITE #420E
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City | GREENWOOD VILLAGE
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State | CO
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Zip | 80111-2803
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Country | US
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Telephone | 303-740-7088
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. PATRA WATANA
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Credential |
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Telephone | 303-740-7088
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 6614
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License Number State | CO
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