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General NPI Number Information
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NPI Number | 1275924425
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Entity Type | Organization
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Legal Business Name | PEDO LAKEWOOD LLC
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Dates
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Enumeration Date | 02/10/2015
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Last Update Date | 02/10/2015
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Provider Practice Location Address
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Address Line | 9990 W 26TH AVE
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City | LAKEWOOD
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State | CO
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Zip | 80215-1581
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Country | US
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Telephone | 303-202-0880
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Fax | 303-202-0882
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Provider Business Mailing Address
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Address Line | 9990 W 26TH AVE
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City | LAKEWOOD
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State | CO
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Zip | 80215-1581
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Country | US
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Telephone | 303-202-0880
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Fax | 303-202-0882
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Authorized Official
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Title or Position | MANAGER OF PEDO LAKEWOOD LLC
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Name | JEREMY CATMULL
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Credential |
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Telephone | 801-885-0635
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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 | 00202066
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License Number State | CO
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