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General NPI Number Information
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NPI Number | 1346679321
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Entity Type | Organization
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Legal Business Name | MOD LLC
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Dates
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Enumeration Date | 11/11/2013
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Last Update Date | 12/01/2016
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Provider Practice Location Address
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Address Line | 2121 MIDPOINT DR SUITE 102
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City | FORT COLLINS
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State | CO
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Zip | 80525-4339
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Country | US
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Telephone | 970-484-5437
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Fax | 970-484-5436
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Provider Business Mailing Address
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Address Line | 2121 MIDPOINT DR SUITE 102
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City | FORT COLLINS
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State | CO
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Zip | 80525-4339
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Country | US
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Telephone | 970-484-5437
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Fax | 970-484-5436
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Authorized Official
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Title or Position | PEDIATRIC DENTIST
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Name | LUKE MILMONT
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Credential |
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Telephone | 307-772-1793
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State | CO
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