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General NPI Number Information
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NPI Number | 1114166865
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Entity Type | Organization
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Legal Business Name | PEDO TWO, PROF. LLC
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Dates
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Enumeration Date | 02/19/2009
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Last Update Date | 09/25/2023
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Provider Practice Location Address
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Address Line | 7475 W COLFAX AVE STE 103
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City | LAKEWOOD
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State | CO
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Zip | 80214-5425
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Country | US
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Telephone | 720-512-2879
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Fax | 720-241-7811
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Provider Business Mailing Address
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Address Line | 6870 S UNIVERSITY BLVD
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City | CENTENNIAL
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State | CO
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Zip | 80122-1515
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Country | US
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Telephone | 720-512-5879
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Fax | 720-241-7811
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Authorized Official
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Title or Position | PRESIDENT
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Name | COLTON FLAKE
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Credential | DDS
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Telephone | 720-277-5930
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 10630
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 10630
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License Number State | CO
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Taxonomy #3
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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