=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154651909
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROSMILE OF LOVELAND, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2009
-----------------------------------------------------
Last Update Date | 12/29/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2502 ABARR DR
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80538-3156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-669-1444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2502 ABARR DR
-----------------------------------------------------
City | LOVELAND
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80538-3156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-669-1444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER MANAGER
-----------------------------------------------------
Name | MICHAEL SCOT FREIMUTH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 970-669-1444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 7288
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------