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General NPI Number Information
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NPI Number | 1245256643
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Entity Type | Organization
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Legal Business Name | GOVERNOR'S PARK DENTAL GROUP
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Dates
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Enumeration Date | 07/15/2006
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Last Update Date | 10/17/2007
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Provider Practice Location Address
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Address Line | 700 E 9TH AVE SUITE 102
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City | DENVER
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State | CO
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Zip | 80203-3360
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Country | US
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Telephone | 303-832-7789
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Fax | 303-832-0427
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Provider Business Mailing Address
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Address Line | 700 E 9TH AVE SUITE 102
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City | DENVER
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State | CO
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Zip | 80203-3360
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Country | US
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Telephone | 303-832-7789
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Fax | 303-832-0427
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Authorized Official
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Title or Position | OWNER
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Name | TERRY L BREWICK
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Credential | D.D.S.
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Telephone | 303-832-7789
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 105046
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License Number State | CO
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