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General NPI Number Information
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NPI Number | 1366912180
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Entity Type | Organization
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Legal Business Name | MY LOCAL COLORADO DENTAL PRACTICE, LLC
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Dates
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Enumeration Date | 12/05/2018
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Last Update Date | 12/05/2018
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Provider Practice Location Address
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Address Line | 2721 W 120TH AVE STE 200
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City | WESTMINSTER
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State | CO
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Zip | 80234-2946
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Country | US
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Telephone | 303-586-6985
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Fax | 719-213-2311
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Provider Business Mailing Address
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Address Line | 6110 BARNES RD
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City | COLORADO SPRINGS
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State | CO
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Zip | 80922-2600
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | MICHELLE JOHNSON
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Credential |
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Telephone | 509-315-8338
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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 |
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